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Home
About
Weight Loss Program
IV Hydration Therapy
Health & Wellness
Preventive Annual Physical
Sick Visits
Hormone Replacement Therapy
High Blood Pressure
Erectile Dysfunction
Hair Loss
Thyroid Management
Insurance & Billing
MedGo Intake QuizW
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Details
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Details
Details
Check Eligibility
Reach your goal weight fast without restrictive diets and exercise.
Please answer the following questions so we can qualify you for medical weight loss. We are only serving Texas patients at this time so we can provide the best possible care and a more focused one-on-one experience.
What is your height and weight?
Feet
4
5
6
7
Inches
*
1
2
3
4
5
6
7
8
9
10
11
Weight (in lbs)
*
What is your goal weight?
*
Are you a male of female?
Female
Male
What is your date of birth? (Must be older than 18)
*
Do any of these apply to you?
*
Currently or possibly pregnant, or actively trying to become pregnant
Breastfeeding or bottle-feeding with breastmilk
Have given birth to a child within the last 6 months
None of the above
Health Questions 1: Do any of these apply to you?
*
End-stage kidney disease (on or about to be on dialysis)
End-stage liver disease (cirrhosis)
Current suicidal thoughts and/or prior suicidal attempt
Cancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years - does not apply to non-melanoma skin cancer that was considered cured via simple excision)
Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)
Current diagnosis of or treatment for alcohol, opioid, or substance use disorder/dependence
None of the above
Health Questions 2: Do any of these apply to you?
*
Gallbladder disease
Hypertension (high blood pressure)
Seizures
Glaucoma
Sleep apnea
Type 2 diabetes (not on insulin)
Type 2 diabetes (on insulin)
Type 1 diabetes
Diabetic retinopathy (diabetic eye disease), damage to the optic nerve from trauma or reduced blood flow, or blindness
Use of the blood thinner warfarin (Coumadin/Jantoven)
History of or current pancreatitis
Personal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2
Gout
High cholesterol or triglycerides
Depression
Head injury
Tumor/infection in brain/spinal cord
Low sodium
Liver disease, including fatty liver
Kidney disease
Elevated resting heart rate (tachycardia)
Coronary artery disease or heart attack/stroke in last 2 years
Allergic to any medication
Congestive heart failure
QT prolongation or other heart rhythm disorder
Hospitalization within the last 1 year
Human immunodeficiency virus (HIV)
Acid reflux
Asthma/reactive airway disease
Urinary stress incontinence
Polycystic ovarian syndrome (PCOS)
Clinically proven low testosterone
Osteoarthritis
Constipation
None of the above
Within the last 3 months, have you taken opiate pain medications and/or opiate-based street drugs?
*
No
Yes
Have you had prior weight loss surgeries?
*
No
Yes
Do you currently take any prescription medications
*
No
Yes
What is your blood pressure range?
*
<120/80 (Normal)
120 to 129/<80 (Elevated)
130 to 139/80-89 (High Stage 1)
≥140/90 (High Stage 2)
What is your average resting heart rate?
*
<60 beats per minute (Slow)
60 to 100 beats per minute (Normal)
101 to 110 beats per minute (Slightly Fast)
>110 beats per minute (Fast)
Have you taken medication for weight loss within the past 4 weeks?
*
Yes, I've taken GLP-1 medication
Yes, I've taken a different medication for weight loss
No
If you are human, leave this field blank.
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