Patient Intake Form

HealthSpan By Design Weight Loss Optimization Membership Intake Form

Phone Number *

Please enter your phone number.

First Name *

Last Name *

Date of Birth *

Please enter your date of birth.

Email *

Please provide a valid email address.

BMI less than 27 kg/m² (If Yes, you do not qualify)

Yes

No

BMI greater than 30 kg/m² (If yes, then you qualify pending no contraindications below)

Yes

No

If BMI between 27-29.9 kg/m² Do you have any of the following medical conditions? (Select all that apply)

Not applicable

Hypertension (>130/85)

Dyslipidemia (Triglycerides ≥150 mg/dL and/or HDL <40 mg/dL in men, <50 mg/dL in women)

Type 2 Diabetes

Sleep Apnea

If you are not within this BMI range click not applicable. If you are within this range and select one or more then you qualify pending no contraindications below.

Do you have any of the following contraindications? *

Personal or family history of medullary thyroid carcinoma (MTC)

History of Multiple Endocrine Neoplasia Syndrome Type 2 (MEN2)

Pregnant, planning pregnancy, or breastfeeding

History of pancreatitis

Severe gastrointestinal issues (e.g., gastroparesis)

Severe allergic reaction to GLP-1 medications

Not Applicable

Select all that apply. If none, selecet Not applicable.

Would you like to explore insurance coverage for weight loss medications (Tirzepatide and Semaglutide)? *

Yes, I would like assistance checking insurance coverage.

No, I plan to pay out-of-pocket.

Insurance Provider (If Applicable)

Member ID

Group Number

Acknowledgement Statement

If you no longer qualify and need to cancel your consultation, please check your Calendly confirmation email for the cancellation link.

Welcome to Healthspan by Design

Complete a short intake form below

HealthSpan By Design Weight Loss Optimization Membership Intake Form