Body4EverNOW Intake Form - Body4Ever Now

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Please fill in the details below to complete your purchase.

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First Name *

Last Name *

Email *

Phone Number (xxx) xxx-xxxx *

Shipping Address *

Unit / Apartment Number

City *

State *

Zip *

Birthdate *

Height (Feet, Inches) *

Weight (Pounds) *

Gender at Birth *

Male
Female

Are you currently taking any medication? *

Yes
No

Do you have any medical conditions, past or present? *

Yes
No

Are you taking semaglutide currently? *

Yes
No

Are you currently taking any diet medication? *

Yes
No

Do you have any medication allergies? *

Yes
No

How often do you consume alcohol?

Daily
Weekly
Monthly
Occasionally
Never

any any Be

What is the primary reason(s) that you are seeking weight loss treatment and what are your goals about weight control and management at this time? *

Do you have or have you ever had any of the following conditions? (Check all that apply) *

Cancer
Diabetes
High Blood Pressure
Gallbladder Problems
Skin Disorders
Keloid Scarring
Hyper/Hypopigmentation
Pancreatitis
Thyroid Problems
Kidney Problems
Hepatitis
Blood Clotting Disorders
Hormone Deficiency
Gastroparesis
Chronic Abdominal Pain
Illness in last 30 days
NONE OF THE ABOVE

Do you have a history of any of the following? *

Medullary Thyroid Cancer
Multiple Endocrine Neoplasia
Pancreatic Cancer
Type I Diabetes
None of the Above

Do you have any other health problems or medical conditions not listed above? *

Yes
No

Are you pregnant or trying to get pregnant? *

Yes
No

Have You Or A Family Member Ever Had A History Of Medullary Thyroid Carcinoma, Or Multiple Endocrine Neoplasia Type 2 (Men 2)? *

Yes
No

Have You Ever Had Gastroparesis, Pancreatitis, Ulcerative Colitis, Chron's Disease, Diverticulosis/ Itis That Could Be Worsened By Slow Gastric Emptying ? *

Yes
No

Do You Have A History Of Moderate To Severe Renal Disease? *

Yes
No

Are You Pregnant Or Breastfeeding? Are You Considering Becoming Pregnant In The Next 3 Months? *

Yes
No

Do You Have A History Of Eating Disorders, Or Depression? *

Yes
No

Have You Ever Had An Allergy To Any Oof The Glp-1s Or Their Components? *

Yes
No

If You Are Diabetic Have You Ever Been Diagnosed With Retinopathy Or Eye Problems? *

Yes
No

Do You Have A History Of Gallstones? *

Yes
No

Signature *

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