MedsConnect | Weight Management Qualifier

Let’s begin

Tell us your current height and weight.

We’ll use these measurements to calculate a preliminary BMI for this intake.

FeetInchesCurrent weight (lb)

Your goal

What weight would you like to work toward?

This helps personalize your intake. A licensed clinician will determine what is appropriate for you.

Goal weight (lb)

Your experience

Where are you in your weight-management journey?

I’m exploring treatment for the first timeI’ve tried lifestyle changes but need more supportI’ve used prescription weight-loss treatment beforeI’m currently using a treatment

About you

What sex were you assigned at birth?

This may affect which medical questions are relevant later in the intake.

FemaleMalePrefer not to say

Current experience

Which of these have been part of your experience recently?

Select all that apply.

Frequent hunger or food cravingsLow energyDifficulty maintaining weight lossWeight-related confidence concernsA weight-related health concernNone of these

Your priority

What would matter most in a treatment plan?

Steady, sustainable progressReducing hunger and cravingsImproving energy and daily routineSupport and accountability

Your motivation

What is your main reason for focusing on weight management now?

I want to feel healthier day to dayI want to feel more comfortable and confidentI’m preparing for an important life eventA healthcare professional recommended itSomething else

Your expectations

What kind of progress would feel right for you?

Gradual and consistentModerate, with regular check-insI’m open to the clinician’s recommendation

Daily health

How would you describe your sleep overall?

Very goodMostly goodInconsistentPoor

Daily health

About how much sleep do you usually get each night?

Less than 5 hours5–6 hours7–8 hoursMore than 8 hours

Health history

Have you ever been diagnosed with any of the following?

Select all that apply. These answers would require confirmation by a licensed clinician.

Medication history

Have you used prescription weight-loss medication during the last four weeks?

Yes, I’m currently taking oneYes, but I recently stoppedNoI’m not sure

Medication history

Within the past three months, have you used opioid pain medication or other opioid substances?

YesNoI’m not surePrefer to discuss with a clinician

Surgical history

Have you had a weight-loss procedure or bariatric surgery?

Yes, within the last 6 monthsYes, more than 6 months agoNo

Previous approaches

Have you tried a structured weight-management program before?

Yes, and I completed one or more programsYes, but I found it difficult to maintainNo, this would be my first structured program

Treatment readiness

If clinically appropriate, which changes would you be willing to make?

Select all that apply.

Follow a clinician-directed treatment planMake practical nutrition changesIncrease movement when appropriateComplete follow-up check-ins

Recent history

How has your weight changed over the past year?

It has increasedIt has stayed about the sameIt has decreased intentionallyIt has decreased without trying

Recent vitals

What ranges are closest to your usual blood pressure and resting heart rate?

Choose “I don’t know” if you do not have recent readings.

Blood pressureResting heart rate

Current medications

Are you currently taking any medications or supplements?

List names and doses when known. Leave blank if none. For urgent medical concerns, seek immediate medical attention.

0/1000 characters

Anything else

Is there any other health information a medical team should know?

Optional.

0/1000 characters

Treatment preferences

Which options would you be open to discussing with a clinician?

Select up to two. This does not guarantee a prescription or treatment type.

Weekly injectable optionsNon-injectable optionsI’d like clinical guidance

Personal details

Tell us a little about yourself.

Provide the details below to continue your intake.

First nameLast nameDate of birthState

Contact details

How should the care team reach you if needed?

.

Email addressMobile phone

Final review

Review your answers before checking your eligibility result.

This eligibility result is not a diagnosis, medical approval, or prescription decision.

Check the information below. Use any Edit button to return to that question without losing your other answers.

Let’s learn what kind of support may fit your goals.

Tell us your current height and weight.

What weight would you like to work toward?

Where are you in your weight-management journey?

What sex were you assigned at birth?

Which of these have been part of your experience recently?

What would matter most in a treatment plan?

What is your main reason for focusing on weight management now?

What kind of progress would feel right for you?

How would you describe your sleep overall?

About how much sleep do you usually get each night?

Have you ever been diagnosed with any of the following?

Have you used prescription weight-loss medication during the last four weeks?

Within the past three months, have you used opioid pain medication or other opioid substances?

Have you had a weight-loss procedure or bariatric surgery?

Have you tried a structured weight-management program before?

If clinically appropriate, which changes would you be willing to make?

How has your weight changed over the past year?

What ranges are closest to your usual blood pressure and resting heart rate?

Are you currently taking any medications or supplements?

Is there any other health information a medical team should know?

Which options would you be open to discussing with a clinician?

Tell us a little about yourself.

How should the care team reach you if needed?

Review your answers before checking your eligibility result.

Your estimated BMI is —.

Your responses are ready for clinical review.