Skip to content
Pricing
Blog
FAQs
Pricing
Blog
FAQs
Login
Register
ZenFit Medical Intake Screening
Medical Intake
Screening Questionnaire
"
*
" indicates required fields
Name
This field is for validation purposes and should be left unchanged.
This questionnaire is designed to screen patients for eligibility for GLP-1 medications (Semaglutide/Ozempic and Tirzepatide/Zepbound).
Basics & Eligibility
This field is hidden when viewing the form
What is your biological sex?
*
Male
Female
This field is hidden when viewing the form
What is your date of birth?
*
MM slash DD slash YYYY
Current Height:
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
This field is hidden when viewing the form
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
This field is hidden when viewing the form
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
This field is hidden when viewing the form
Are you currently taking any prescription medications?
*
No
Yes
Please list medication name and dosage
*
This field is hidden when viewing the form
Are you currently taking insulin or sulfonylureas (e.g., glipizide, glyburide)?
*
Yes
No
Weight Loss History
This field is hidden when viewing the form
Have you taken GLP-1 medications before?
*
No, never.
Yes, currently taking.
Yes, took in the past.
This field is hidden when viewing the form
Please specify which medication and your last dosage
*
This field is hidden when viewing the form
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
This field is hidden when viewing the form
How would you describe your alcohol consumption?
*
None
Occasional (1-2 drinks/week)
Moderate (3-7 drinks/week)
Heavy (8+ drinks/week)
This field is hidden when viewing the form
Do you use tobacco or nicotine products?
*
Yes
No
Legal & Informed Consent
This field is hidden when viewing the form
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
This field is hidden when viewing the form
Upload Government ID
*
Accepted file types: jpg, jpeg, png, pdf, Max. file size: 256 MB.
This field is hidden when viewing the form
Upload Selfie with ID
*
Accepted file types: jpg, jpeg, png, Max. file size: 256 MB.
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.
