Self-Assessment Tool

Weight Loss (GLP-1) Eligibility Scorecard

Answer the following questions to get a preliminary assessment of your potential eligibility for GLP-1 weight loss medication. This is not a medical diagnosis.

GLP-1 Weight Loss Eligibility

Please answer the following questions to get a preliminary assessment of your eligibility for GLP-1 weight loss medication.

1

What is your height and weight?

ft
in
lbs
2

How many serious weight loss attempts have you made in the past 2 years?

3

Do you have any weight-related health conditions (such as high blood pressure, high cholesterol, type 2 diabetes, sleep apnea, etc.)?

4

Are you currently taking any medications that might interact with GLP-1 medications?

5

Do you have a history of depression, anxiety, or other mental health conditions?

6

Have you been diagnosed with sleep apnea?

7

Do you have a personal or family history of Medullary Thyroid Cancer or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)?

8

Are you currently pregnant?

9

Are you currently breastfeeding?

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