What is your height and weight?
What is your goal weight?
Are you male or female?
Male
Female
What is your date of birth?
Health Questions 1: Do any of these apply to you?
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 or cancer-free for less than 5 continuous years - does not apply to non-melanoma skin cancer that was considered cured via simple excision)
Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)
Current diagnosis of or treatment for alcohol, opioid, or substance use disorder/dependence
None of the above
Health Questions 2: Do any of these apply to you?
Gallbladder disease
Hypertension (high blood pressure)
Seizures
Glaucoma
Sleep apnea
Type 2 diabetes (not on insulin)
Type 2 diabetes (on insulin)
Type 1 diabetes
Diabetic retinopathy (diabetic eye disease), damage to the optic nerve from trauma or reduced blood flow, or blindness
Use of blood thinners (Warfarin/Acenocoumarol)
History of or current pancreatitis
Personal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2
Gout
High cholesterol or triglycerides
Depression
Head injury
Tumor/infection in brain/spinal cord
Low sodium
Liver disease, including fatty liver
Kidney disease
Elevated resting heart rate (tachycardia)
Coronary artery disease or heart attack/stroke in last 2 years
Congestive heart failure
QT prolongation or other heart rhythm disorder
Hospitalization within the last 1 year
Human immunodeficiency virus (HIV)
Acid reflux
Asthma/reactive airway disease
Urinary stress incontinence
Polycystic ovarian syndrome (PCOS)
PCOD/hormonal imbalance
Osteoarthritis
Constipation
Within the last 3 months, have you taken opiate pain medications and/or opiate-based street drugs?
Yes
No
Have you had prior weight loss surgeries?
Do you currently take any prescription medications?
What is your blood pressure range?
<120/80 (Normal)
120 to 129/<80 (Elevated)
130 to 139/80-89 (High Stage 1)
≥140/90 (High Stage 2)
What is your average resting heart rate?
<60 beats per minute (Slow)
60 to 100 beats per minute (Normal)
101 to 110 beats per minute (Slightly Fast)
>110 beats per minute (Fast)
Have you taken medication for weight loss within the past 4 weeks?
Yes, I've taken GLP-1 medication
Yes, I've taken a different medication for weight loss
Have you ever tried to lose weight in a weight management program?
Which of these is most important to you?
Affordability (Low price)
Potency (Stronger dose)
GLP-1 is available as an injection or a dissolvable tablet. Which sounds best?
I prefer to inject (One injection per week)
I prefer a tablet (One tablet per day)
Have any further information which you would like our medical team to know?
Please select the following options that you are interested in
Lose weight effectively
Reduce appetite and cravings
Improve energy levels
Manage blood sugar
Would prefer not to inject
Improve sleep quality
I'd like to discuss options with a doctor first
Your Full Name
Full Address
Email
Phone Number
I understand my information is protected under India's Digital Personal Data Protection Act 2023. My health information will be shared with ZIVOLABS' licensed medical partners (doctors and pharmacies) solely for the purpose of my consultation and treatment. It will never be sold or shared with third parties for marketing. I confirm I am above 18 years of age.
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