ARE YOU ELIGIBLE FOR GLP-1 MEDICATIONS?

Please complete the form below and a licensed medical provider at Path Health will determine your eligibility. Information provided will be carefully reviewed and used to determine recommendations.

First Name

Last Name

phone

Date of Birth (MM/DD/YYYY)

Sex

female male

State of Residence

Client Health Information

Height (inches):

Current Weight (lbs):

BMI

Pregnant or plan to become pregnant:

Yes No

Breastfeeding?

Yes No

Other:

Past Surgical History (check all that apply):

Gallbladder Bariatric Surgery None

Other Surgery

Current Medications (if no medications, type none)

Do you have or had any of the following? (check all that apply):

Desired Weight Loss Medication

Describe your goals (check all that apply):

Lose weight or maintain healthy weight Improve known medical conditions Improve energy levels Increase lean muscle mass Improve physical health and activity levels Boost confidence, mood and overall appearance Learn better daily lifestyle habits

By checking this box, you indicate that you, as the patient or legal guardian of the client, agree to the Terms of Service, Privacy Policy and Consent to Telehealth (if applicable).

Path Health is a health and wellness company/practice that is dedicated to improving the lives of our clients by helping them to create a personalized roadmap on their journey to improved health.

ARE YOU ELIGIBLE FOR GLP-1 MEDICATIONS?

ARE YOU ELIGIBLE FOR GLP-1 MEDICATIONS?

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