Intake Questions – Northwestern Weight Loss

Step 1 of 17

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Provider ID (Hidden)

Are you at least 18 years old and live in Illinois?

Yes

We're Sorry

Based upon your answer, we are unable to treat you. State laws require you to be at least 18 years old and live in Illinois to receive our services.

What is your current weight in pounds?(Required)

What is your height?

Feet(Required)

Inches(Required)

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Total height in inches

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BMI

How much weight do you want loose?

0-10 lbs

1-20 lbs

21-30 lbs

31-40 lbs

41-50 lbs

More than 50 lbs

We're Sorry

Based upon your answer, we are unable to treat you. Our program is specifically tailored to help people loose up to 50 lbs. This does not mean you may not be a candidate for semaglutide. We recommend that you ask your primary care physician for a specialist in their network.

Have you ever had any of the following conditions?(Required)

Semaglutide may impact these conditions so it is important that we know.

Diabetes

Eating disorder

Suicidal ideation or behavior

Alcohol misuse or abuse

Retinopathy

Pancreatitis or pancreas disease

Gallstones or other gallbladder disease

Kidney disease

Liver disease

None of the above

We're Sorry

Based upon your answer, we are unable to treat you. This does not mean you may not be a candidate for semaglutide. We recommend that you ask your primary care physician for a specialist in their network.

Do you have a personal or family history of medullary thyroid cancer?(Required)

Yes

We're Sorry

Do you have a personal or family history of Multiple Endocrine Neoplasia type 2 (MEN2)(Required)

Yes

We're Sorry

Are you taking any of the following medications?(Required)

Select all that apply

Insulin

Metformin

Sulfonylureas such as glipizide (Glucotrol) or glimepiride (Amaryllis)

Megalitinides such as repaglinide or nateglinid

Directics such as furosemide (Lasix), bumetanide (Bumex) or Hydrochlorothiazide (HCTZ)

Bexarotene

Gatifloxicn

None of the above

We're Sorry

Do you have plans to start or grow your family within the next 6 months?(Required)

This includes you or your partner becoming pregnant, undergoing fertility treatments, or undergoing IVF.

Yes

We're Sorry

Great News. You're Eligible

The next step is to schedule a consultation virtually or in-person with Dr. Vinay.

Name

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