Customer Details

First Name

Last Name

Email Address

Phone Number

Ethnicity

Height

cmft/in

Weight

kgstone/lbs

Currently pregnant, trying to get pregnant, or breastfeeding?

Yes

No

Has the customer been diagnosed with diabetes?

Yes

No

Does the customer suffer from any of the following?Select all that apply

Liver, kidney or heart failure

Pancreatitis

Multiple endocrine neoplasia type 2

Cancer

Type 1 diabetic retinopathy

Personal or family history of medullary thyroid cancer

History of an eating disorder (e.g anorexia, bulimia)

History of gallbladder problems

History of inflammatory bowel disease or gastroparesis

List any medical conditions Type N/A if they don’t have any

More about the specific diagnosis and it’s managedSelect all that apply

Diagnosed with a mental health condition such as depression or anxiety

An eating disorder such as bulimia, anorexianervosa, or a binge eating disorder

None of these statements apply

More about the specific diagnosis and it’s managed