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First Name:*

Last Name:*

Your Email:*

Date of Birth*

MM slash DD slash YYYY

Our maximum age for weight loss medications is 70.

Cell Phone:*

Height (ft):*

Please enter a number from 4 to 7.

(for example for 5' 2", enter 5)

Inches:*

Please enter a number from 0 to 11.9.

(for example for 5' 2", enter 2)

Weight (lbs):*

Please enter a number from 100 to 1000.

BMI:

Preferred Appointment Location:*

First appointment must be in-person!

Your BMI is too low for initiation of treatment with weight loss medications. Ohio requires a BMI over 27.

Your BMI is too low for initiation of treatment with weight loss medications. Kentucky requires a BMI over 25, and Ohio requires a BMI over 27.

Are you currently being treated for any of the following issues?*

I have none of these issues

Fatty liver

High cholesterol or triglycerides

High blood pressure

Major depression

Polycystic Ovary

Type 2 diabetes, pre-diabetes, or insulin resistance

Sleep apnea

Your BMI is too low for initiation of treatment with weight loss medications. Ohio requires a BMI over 30, or a BMI of 27-30 with weight-related medical conditions.

Your BMI is too low for initiation of treatment with weight loss medications. Kentucky requires a BMI over 27, or a BMI of 25-27 with weight-related medical conditions.

Have you had any of these issues in the past?*

I have had none of these issues

Glaucoma

Heart attack

Heart surgery or stent

Irregular heart beat or atrial fib

Seizures

Stroke

Uncontrolled high blood pressure

Do you currently take any of the listed medications?*

I do not take any of these

Adderral (dextroamphetamine)

Focalin (dexmethylphenidate)

Ritalin (methylphenidate)

Vyvanse (lisdexamfetamine)

Methadone (Dolophine or Methadose)

Subutex/Suboxone (buprenorphine)

Vivitrol (naltrexone)

Medication Interest(s):*

Adipex (phentermine)

Contrave

Qsymia

Saxenda

Tenuate (diethylpropion)

Wegovy

Unsure (or other)

Have you received a prescription for an appetite suppressant from any provider within the last 3 months?*

Yes

Not sure

We require a minimum medication-free break of 3 months before re-starting treatment.

Have you seen us for medical weight loss in the last 12 months?*

Yes

Not Sure

Are you currently pregnant or nursing?*

Yes

N/A

Patients who are pregnancy or nursing are not candidates for weight loss medications.

Do you have a history of drug abuse or addiction?*

Yes

Please note that a controlled substance report will be reviewed prior to prescribing any medications. Any false or misleading statements regarding medical conditions, substance abuse history, or recent prescriptions for weight loss medications could result in a permanent ban based on Ohio and Kentucky regulations.

According to the State Medical Boards of Ohio and Kentucky, patients with a current (or past) history of any type of substance abuse disorder are not eligible for weight loss medications.

Additional Info

You may not be eligible for weight loss medications based on your medical history. Your information will be reviewed and a team member will be in contact with you.

You may not be eligible for weight loss medications based on your current medications. Your information will be reviewed and a team member will be in contact with you.

By clicking the "Submit" button I attest that all information is accurate, and I give permission for this information to be transmitted via internet to JourneyLite Physicians. The information will be reviewed as soon as possible and you will be contacted by our team.

Comments

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