questionnaire – Skinny Labs Co

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Name *

First

Last

Phone *

How much weight are you looking to lose? *

Ready?

Your Height

Feet

Inches

Your Current weight *

Pounds

What do you want to accomplish with the CosmeticRx Body Program *

Do you currently have, or have you ever been diagnosed with, any of the following heart or heart-related conditions? *

Do you currently have, or have you ever been diagnosed with, any of these hormone, kidney, or liver conditions? *

with of to

Do you currently have, or have history of, any of these gastrointestinal conditions or procedures? *

Do you currently have, or have you ever been diagnosed with, any of these additional following conditions? *

Chronic candidiasis (fungal infection)
Eating disorder
Gout
History of suicide attempt or history of suicidal ideation.
Lymphedema or chronic lower extremity swelling where other causes have been ruled out
Metabolic syndrome
Obstructive sleep apnea
Osteoarthritis
Tinea infections (skin folds)
No, I have not been diagnosed with any of these conditions or procedures

List any allergies that you have

Allergies

Do you have an allergy to GLP-1 agonist medications? *

Examples include tirzepatide (Zepbound/Mounjaro), liraglutide (Saxenda/Victoza), semaglutide (Wegovy/Ozempic), and dulaglutide (Trulicity)

Do you currently take any of the following medications? *

A GLP-1 agonist such as (but not limited to) semaglutide (Wegovy/Ozempic), liraglutide (Saxenda/Victoza), dulaglutide (Trulicity), tirzepatide (Zepbound/Mounjaro)
Sulfonylureas such as (but not limited to) glipizide (Glucotrol), glimepiride (Amaryl)
Insulin
Warfarin (also called Jantoven or Coumadin) - a blood thinner that usually requires regular lab testing
Meglitinides such as repaglinide or nateglinide
Diuertics such as (but not limited to) furosemide (Lasix), bumetanide (Bumex) Hydrochlorothiazide/HCTZ
Selective Seroonin Reuptake Inhibitors (SSRIs) such as (but not limited to) citalopram (Celexa), fluoxetine (Prozac), escitalopram (Lexapro)
Monoamine Oxidase Inhibitors (MAOIs) such as (but not limited to) phenelzine (Nardil), selegiline (Emsam)
None of the above

List any medications that you take.

Is there anything else you want your healthcare provider to know about your health? *

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Email *

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