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ZenFit Medical Intake Screening

Quick Qualifier

Complete eligibility assessment

"*" indicates required fields

Step 1 of 2

50%

Phone

This field is for validation purposes and should be left unchanged.

This questionnaire is designed to screen patients for eligibility for GLP-1 medications (Compounded Semaglutide/Compounded Tirzepatide).

Email*

Full name*

What is your biological sex?*

Male

Female

What is your date of birth?*

MM slash DD slash YYYY

Allergies*

Weight (lbs)*

Height (feet)*

Please enter a number from 3 to 8.

Height (inches)*

Please enter a number from 0 to 11.

Are you currently pregnant, breastfeeding, or planning to become pregnant in the next 3 months?*

Yes

No

Do you or any family member have a history of Medullary Thyroid Carcinoma (MTC)?*

Yes

No

This field is hidden when viewing the form

Feet*

Please enter a number from 3 to 8.

This field is hidden when viewing the form

Inches*

Please enter a number from 0 to 11.

This field is hidden when viewing the form

Current Weight (lbs)*

Please enter a number from 50 to 800.

This field is hidden when viewing the form

Are you currently pregnant, breastfeeding, or planning to become pregnant in the next 3 months?*

Yes

No

N/A

This field is hidden when viewing the form

What is your goal weight? (lbs)*

Safety & Contraindications

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Do you or any family member have a history of Medullary Thyroid Carcinoma (MTC)?*

Yes

No

This field is hidden when viewing the form

Do you have a history of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)?*

Yes

No

This field is hidden when viewing the form

Have you ever had pancreatitis (inflammation of the pancreas)?*

Yes

No

This field is hidden when viewing the form

Do you have Type 1 Diabetes?*

Yes

No

This field is hidden when viewing the form

Have you ever had a serious allergic reaction to Semaglutide (Ozempic/Wegovy) or Tirzepatide (Mounjaro/Zepbound)?*

Yes

No

This field is hidden when viewing the form

Do you have a history of suicidal thoughts or attempts?*

Yes

No

Medical History

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Have you been diagnosed with any of the following? (Select all that apply)*

High Blood Pressure

High Cholesterol

Heart Disease

Kidney Disease

Liver Disease

Gallbladder problems

Diabetic Retinopathy (Eye problems)

Gastroparesis (Stomach paralysis)

None of the above

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Are you currently taking any prescription medications?*

No

Yes

Please list medication name and dosage*

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Are you currently taking insulin or sulfonylureas (e.g., glipizide, glyburide)?*

Yes

No

Weight Loss History

Have you taken GLP-1 medications before?*

No

Yes

Please list your previous medications and dosages*

Medication

Last Dosage / Week

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Please specify which medication and your last dosage*

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What other weight loss methods have you tried? (Select all that apply)

Diet & Exercise

Commercial programs (WeightWatchers, Noom, etc.)

Other prescription meds (Phentermine, Contrave, etc.)

Supplements

Lifestyle

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How would you describe your alcohol consumption?*

None

Occasional (1-2 drinks/week)

Moderate (3-7 drinks/week)

Heavy (8+ drinks/week)

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Do you use tobacco or nicotine products?*

Yes

No

Legal & Informed Consent

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Telehealth Consent*

I acknowledge that I am engaging in a telehealth consultation. I understand that the provider will rely on the accuracy of the information I provide. I agree to contact emergency services immediately in case of a medical emergency.

This field is hidden when viewing the form

Personal Importation Agreement*

I understand that my medication is being sourced internationally via Progressive Global (Canada/Philippines) to provide cost savings. I affirm I am the importer of record for my personal use only.

This field is hidden when viewing the form

Off-Label Use Acknowledgement*

I understand that while Semaglutide/Tirzepatide are FDA-approved for Type 2 Diabetes (Ozempic/Mounjaro) or Weight Management (Wegovy/Zepbound), my specific prescription may be considered "off-label" depending on my diagnosis and the specific product sourced.

This field is hidden when viewing the form

Refund Policy Acknowledgement*

I understand that if I am medically approved and the prescription is sent to the pharmacy, the Medication Cost is non-refundable. If I am denied treatment, I will receive a 100% refund.

Verification

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Upload Government ID*

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 2 GB.

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Upload Selfie with ID*

Accepted file types: jpg, jpeg, png, Max. file size: 2 GB.

This field is hidden when viewing the form

BMI

This field is hidden when viewing the form

Eligibility Status

✓ Congratulations! You Qualify. Based on your responses, you are eligible for GLP-1 medication consultation. Click below to proceed to our shop.

✗ Not Eligible at This Time. Based on your responses, you do not meet the eligibility criteria for GLP-1 medications at this time. Please consult with your healthcare provider for alternative options.

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Medical Disclaimer: ZenFit Wellness is a telehealth platform. All prescriptions are issued by licensed clinicians following a medical intake review. GLP-1 medications are not appropriate for everyone. Individual results may vary. Compounded medications are prepared by licensed 503A compounding pharmacies and contain the same active ingredients as brand-name medications but are not FDA-approved finished drug products. This website is for informational purposes only and does not constitute medical advice.

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