Weight Loss - V LINE AESTHETICS

Currently or possibly pregnant, or actively trying to become pregnant

Breastfeeding or bottle-feeding with breastmilk

End-stage kidney disease (on or about to be on dialysis)

End-stage liver disease (cirrhosis)

Current or prior eating disorder (anorexia/bulimia)

Current suicidal thoughts and/or prior suicidal attempt

Cancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years; doesn't apply to non-melanoma skin cancer that was considered cured via simple excision alone)

History of organ transplant on anti-rejection medication

Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)

Do you live in California?

What is your weight loss goal?

What is your height?

What is your weight?

YOUR BMI:

What is your gender?

What is your date of birth?

Do any of the following apply to you?

Are you currently taking or have recently (within the last 12 months) taken medication(s) for weight loss?

Do you currently take any medications?

Do you have any other significant past medical history?

Have you ever attempted to lose weight in a weight management program, such as through caloric restriction, exercise, or behavior modification?

How has your weight changed in the last 12 months?

Are you willing to

Have you ever been diagnosed with diabetes or pre-diabetes?

What was your most recent fasting glucose?

What was your most recent Hemoglobin A1c?

What is your current or average blood pressure range?

Do you have any medication allergies?

Are you concerned about any of the following to the level of impacting your ability to take medication regularly?

Do you have any further information which you would like the provider to know?

What is your first and last name?

What is your email?

What is your phone number?

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