Youthology Semaglutide Prequalification

1
What is your full name as it appears on your government issued ID?
First Name
Last Name
2
What is your email address for a copy of these responses?* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
What is your birthdate?* This field is required.
Date
Year
Month
Day
5
Are you a biological male or female?* This field is required.
Male
Female
6
Do you have challenges losing weight?* This field is required.
YESNO
7
Do you have problems with blood sugar control?* This field is required.
YESNO
8
Do you have Type I Diabetes Mellitus?* This field is required.
YESNO
9
Do you have Type II Diabetes Mellitus?* This field is required.
YESNO
10
Do you have past medical history for pancreatitis or alcohol abuse?* This field is required.
YESNO
11
Do you or a family member have a history of thyroid cancer?* This field is required.
YESNO
12
Do you or a family member have a history of multiple endocrine neoplasia type II?* This field is required.
YESNO
13
Do you have a history of eye problems? Diabetic retinopathy?* This field is required.
YESNO
14
Do you have a history of renal disease or kidney dysfunction?* This field is required.
YESNO
15
Have you been treated with any of the following medications?
Rybelsus
Wygovy
Ozempic
Mounjaro
16
When was your last dose administered and what was the dosage?
17
Do you have a history of gallbladder disease?* This field is required.
YESNO
18
Are you capable of and willing to perform injections?* This field is required.
YESNO
19
Do you have a history of hypoglycemia?* This field is required.
YESNO
20
Have you been diagnosed with PCOS (Polycystic Ovarian Syndrome)?* This field is required.
YESNO
21
Are you pregnant?* This field is required.
YESNO
22
Are you experiencing any of the following symptoms? Check all that apply.
Brain Fog
Memory Issues
Word Recall Difficulty
None of the Above
23
Do you have fatty liver or non-alcoholic fatty liver disease?* This field is required.
YESNO
24
Do you have any allergies (food, medicine, or both)?* This field is required.
YESNO
25
Please list all allergies starting with medicine and ending with food allergies:
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Ok
26
Please list add medications you are currently taking, if any.
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Ok
27
Do you have any additional medical information that you feel would be helpful for your doctor to know when reviewing your information and lab results?
0/100
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Ok
28
If approved, what is your shipping address to send the medication?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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Bahrain
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The Gambia
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Lithuania
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Macau
Macedonia
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Malawi
Malaysia
Maldives
Mali
Malta
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Martinique
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Moldova
Monaco
Mongolia
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Montserrat
Morocco
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Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
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Nigeria
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Country
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