Intake - The Invigory

Weight Optimization Program Intake Form

Name *

First

Last

Email *

Phone *

What is your height, weight, or BMI?

Height

Weight

BMI

Do you have challenges losing weight? *

Do you have problems with blood sugar control?

Do you have type I or type II diabetes?

Do you have a history of hypoglycemia (low blood sugar)?

Do you have a history of pancreatitis?

Do you have a history of fatty liver, alcohol abuse, or nonalcoholic fatty liver disease?

Do you or your family have a history of thyroid cancer or MEN type II cancer?

Do you have a history of PCOS (polycystic ovarian syndrome)?

Do you have any food or drug allergies?

Do you have a history of renal problems or kidney dysfunction?

Do you have a history of gallbladder disease?

Have you ever been treated with any of the following: Rybelsus/Wegovy/Ozempic/Mounjaro?

Have you had any lab work done in the last year?

Please list current medications and supplements:

Any additional information you'd like the physician to know:

Please allow 3-5 days for review and email follow up (check spam and junk folders).

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