Medical Questionnaire, New Hope Weight Loss

Step 1: Contra-Indicated Conditions

Please check all that apply. These conditions prevent treatment with GLP-1 medications.

End-stage kidney disease (on or about to be on dialysis) End-stage liver disease (cirrhosis) Current suicidal thoughts and/or prior suicidal attempt Cancer, active diagnosis, active treatment, or in remission/cancer-free less than 5 years (excludes non-melanoma skin cancer cured via simple excision) History of organ transplant on anti-rejection medication Severe gastrointestinal condition (e.g., gastroparesis, inflammatory bowel disease) Current diagnosis of or treatment for an eating disorder (anorexia nervosa or bulimia nervosa) Personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia Syndrome Type 2 (MEN-2) Currently pregnant, breastfeeding, or planning to become pregnant within 2 months

None of these conditions apply to me

We're Unable to Proceed

Thank you for walking through our Medical History/Medical Intake questionnaire. Please seek the advice and counsel of your Primary Care Physician (PCP) as we will be unable to progress further. Any monies paid will be fully refunded.

Step 2: Additional Health History

Check all that apply. This information will be reviewed by our physician to ensure safe, personalized treatment.

None of these conditions apply to me

Step 3: Your Contact Information

Enter your details so our medical team can reach you after physician review.

First Name *

Last Name *

Date of Birth *

Email *

Phone *

Shipping / Mailing Address

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City *

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