GLP-1 Weight Loss — Health Questionnaire

About you

We need this to ship your medication and verify your identity.

First name Last name Email Phone Date of birth Biological sex

Shipping address

Street address Apt / Suite (optional) City State ZIP

General health history

Basic background the physician needs to review.

Height (feet) Height (inches) Current weight (lbs) Target weight (lbs)

Current medications (include dose if known — separate with commas) Drug or food allergies Major medical conditions (current or past)

GLP-1 candidacy screening

A few targeted questions so the physician can write the right script safely.

Have you used a GLP-1 medication before? (Ozempic, Wegovy, Mounjaro, Zepbound, compounded semaglutide / tirzepatide) No, this would be my first Yes, currently taking Yes, previously taken

Type 2 diabetes status No diabetes Prediabetic / borderline Yes, Type 2 diabetic

Do you have a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN-2)?

⚠ This is an absolute contraindication for GLP-1 medications.

No Yes Unsure

Have you had pancreatitis?

⚠ Caution flag — physician will review carefully.

No Yes

Do you have a history of gallbladder disease or severe GI disease (gastroparesis, IBD)? No Yes

Anything else the physician should know? (optional)

Pick your GLP-1 program

Your physician makes the final call during review — but you can indicate your preference here. Each subscription bundles the consult, the medication, and ongoing follow-ups as needed.

GLP-1 Program

Semaglutide

Wegovy / Ozempic-class. The original. Smoother side-effect profile for many.

$199/month

GLP-2 Program

Tirzepatide

Mounjaro / Zepbound-class. Dual GLP-1 + GIP agonist. Average 20–22% body-weight loss over 72 weeks.

$249/month

GLP-3 Program

Retatrutide

Triple agonist — GLP-1 + GIP + glucagon. The most aggressive metabolic effect available.

$299/month

Save your payment method

⚡ Your card will not be charged today. It is saved securely with Stripe and will only be charged once a physician reviews your case and approves your script. If you are not approved, no charge is made.

By continuing you authorize My4MLife and our network physicians to use this saved payment method to charge your selected monthly subscription if and when a script is written for you. You can cancel anytime by emailing support@my4mlife.com.

Review and submit

Confirm everything looks right. After submission, our care coordinator will email you within 24 hours to confirm next steps with the network physician.

I attest the information above is accurate to the best of my knowledge. I understand a real physician will review my submission, and that no medication will ship without a written script. I authorize My4MLife and the network physician to contact me by email or phone. I acknowledge I have received and reviewed My4MLife's Notice of Privacy Practices. I authorize My4MLife and its network physicians to use and disclose my health information to provide, coordinate, and bill for my care, including forwarding my intake to the telemedicine provider, as described in the Patient Authorization & Telehealth Consent.

✓

Your submission is in.

Our care coordinator will email you within 24 hours to confirm the next step with the network physician. Your card has been saved securely with Stripe — no charge has been made and none will be made until your script is approved.

Questions? Email support@my4mlife.com.

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