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Thank You for Your Honesty

Based on your responses, GLP-1 treatment may not be the best option for you at this time.

We recommend consulting with your healthcare provider to discuss alternative treatment options that may be more suitable for your specific health situation.

Why this matters:

Your safety is our top priority. Certain medical conditions may increase the risk of complications with GLP-1 medications. A healthcare provider can help you explore safer alternatives.

Please double-check these answers

One or more of your answers means we can't continue. Before we stop, have another look — if any of these was selected by mistake, you can correct it here.

Please answer every question above before continuing.

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Preliminary
Health
Details
Eligibility

Let's check your eligibility for GLP-1 treatment.

We'll use these numbers to calculate your BMI and build your treatment profile.

What is your height and weight?

Height (FT)

Height (IN)

Weight

Goal Weight

Your BMI helps our providers determine if GLP-1 medication is appropriate for you.

Tell us about yourself.

GLP-1 prescriptions require age verification and may involve pregnancy screening.

Date of birth

Day

Year

Sex assigned at birth

Female Male

Why we ask: GLP-1 medications are only prescribed to adults 18+. Biological sex determines pregnancy-related safety screening.

Safety, screening.

Do any of these apply to you?

Currently or possibly pregnant Breastfeeding or bottle-feeding with breastmilk Have given birth to a child within the last 6 months None of the above

Weight gain can have unique effects.

Do you experience any of the following?

Low Libido

Hair Loss

Skin Issues

Cognition Issues

None of these

This helps us tailor your treatment plan. All goals may benefit from GLP-1 therapy.

What is your primary goal?

Lose Weight

Build Muscle

Maintain My Current Body

This helps us tailor your treatment plan. All goals may benefit from GLP-1 therapy.

Your projected timeline

Does this pace work for you?

Yes, that works I'd prefer faster results That seems too fast

Patients on GLP-1 therapy typically see 15–20% total body weight reduction over 12 months.

Medical history: cardiovascular and metabolic

Select any conditions you currently have or have been diagnosed with.

None of these Hypertension High cholesterol Type 2 Diabetes (on insulin or sulfonylureas) Type 1 diabetes Sleep apnea Personal or family history of Medullary Thyroid Carcinoma(MTC), or Multiple Endocrine Neoplasia Syndrome Type 2 (MEN-2) Gout Metabolic syndrome Heart disease, stroke, or peripheral vascular disease Heart Failure Atrial fibrillation or flutter Tachycardia or fast heart rate ECG or heart rhythm abnormality

Why we ask: Certain conditions may affect GLP-1 prescribing. Your answers are reviewed by a licensed provider and protected under HIPAA.

Medical history: organ and systemic conditions

Select any conditions you currently have or have been diagnosed with.

None of these Gallbladder disease Fatty Liver Disease (MASLD or MASH) Cirrhosis or end-stage liver disease End-stage kidney disease Chronic Kidney Disease (Stage 3+) Hypothyroidism Hyperthyroidism, or Thyroid Issues Pancreatitis (history or current) History of or current pancreatitis Diabetic retinopathy On blood thinners/warfarin Cancer (active, in treatment, or in remission <5 years)

Why we ask: Certain conditions may affect GLP-1 prescribing. Your answers are reviewed by a licensed provider and protected under HIPAA.

One more important question

We ask this to ensure your safety and connect you with support if needed.

Are you currently experiencing suicidal thoughts, or have you had a prior suicide attempt?

Yes No

Your answer is confidential and reviewed only by your care team. If you're in crisis, contact the 988 Suicide and Crisis Lifeline by calling or texting 988.

Medication history

Have you taken weight loss medication within the past 4 weeks?

Yes, GLP-1 medication Yes, a different medication No

Please specify your current medication

Compounded Semaglutide Compounded Tirzepatide Mounjaro Wegovy Zepbound Ozempic

Have you used opiate pain medications or opiate-based substances in the past 3 months?

Yes No

Give more details

Why we ask: These medications may interact with GLP-1 therapy. Your provider needs this information for safe prescribing.

When was your last dose?

Select the timeframe

0-7 Days 8-14 Days More than 2 weeks but within the last month Over a month ago

What was the strength of your last dose?

Please provide strength in milligrams (mg) if known

0.25 mg per week 0.50 mg per week 1.00 mg per week 1.50 mg per week 2.50 mg per week

What was the strength of your last dose?

Please provide strength in milligrams (mg) if known

0.25 mg 0.5 mg 1.0 mg 1.7 mg 2.4 mg

What was the strength of your last dose?

Please provide strength in milligrams (mg) if known

0.25 mg 0.5 mg 1.0 mg 2.0 mg

What was the strength of your last dose?

Please provide strength in milligrams (mg) if known

2.5 mg 5.0 mg 7.5 mg 10.0 mg 12.5 mg 15.0 mg

What was the strength of your last dose?

Please provide strength in milligrams (mg) if known

2.5 mg 5.0 mg 7.5 mg 10.0 mg 12.5 mg 15.0 mg

What was the strength of your last dose?

Please provide strength in milligrams (mg) if known

2.5 mg 5.0 mg 7.5 mg 10.0 mg 12.5 mg 15.0 mg

What dosage would you like to continue with?

Select your preferred dosage adjustment

Decrease Dose Stay the Same Increase Dose

Your weight loss background

Have you had weight loss surgery?

Yes No

Give more details

Have you tried weight loss programs?

Yes No

Give more details

How has your weight changed in the past year?

Lost significantly Lost a little About the same Gained a little Gained significantly

Lifestyle alongside treatment

GLP-1 works best combined with healthy habits. If clinically appropriate, are you willing to:

Adjust your caloric intake Increase your physical activity Neither at this time

Your vitals

Approximate ranges are fine.

Blood pressure range

<120/80 (Normal) 120-129/<80 (Elevated) 130-139/80-89 (High Stage 1) ≥140/90 (High Stage 2)

How about your average resting heart rate?

Resting heart rate

<60 bpm (Slow) 60-100 bpm (Normal) 101-110 bpm (Slightly Fast) >110 bpm (Fast)

Anything else your provider should know

Do you currently take any medications?

Yes No

Any additional information for your care team?

Yes No

Your responses are encrypted and HIPAA-protected.

Your Medical Review

Let's proceed to check your eligibility.

BMI:

Current Weight: lbs

Goal Weight: lbs

You are a strong candidate for medical weight loss with a 94% chance of successful treatment if qualified.

First Name

Last Name

What state will your medication be shipped to?

Medication can only be shipped to certain states. Your provider review begins after you complete this form.

How should we reach you?

Your care team uses email and text for appointment updates and prescription status.

Email Address

Phone Number

I confirm that I am the patient completing this intake form and that my answers are accurate and complete to the best of my knowledge. I understand the importance of providing accurate health information for my care. I agree to the Terms of Service and Privacy Policy.

I consent to receive marketing text messages from Nextmeds at the phone number provided, including promotions, discounts, and product/service updates. Msg frequency varies. Msg & data rates may apply. Reply HELP for help, STOP to opt out. Consent is not a condition of purchase.

The health assessment available on this website does not create a provider-patient relationship between the individual completing the assessment and Nextmeds. Medical services, including clinical evaluation and prescribing, are provided by OpenLoop Healthcare Partners, PC and its affiliated professional medical practices. Licensed providers within the OpenLoop Healthcare Partners, PC network apply clinical protocols and exclusionary criteria to determine whether an individual qualifies for treatment. A provider will conduct a telehealth consultation to evaluate medical appropriateness before any prescription is issued. Providers retain sole discretion over all prescribing decisions. A prescription is never guaranteed.

All claims and results referenced on this website reflect self-reported data from members enrolled in the Nextmeds healthcare membership program, which includes telehealth consultations with licensed providers and, where clinically appropriate, compounded GLP-1 medications. Members reported their weight at initial intake and at regular intervals thereafter. Individual results vary and depend on factors including starting weight, program adherence, diet, exercise, and the clinical recommendations of the treating provider. Compounded medications are prepared by state-licensed 503A compounding pharmacies. These medications are not FDA-approved and have not been evaluated by the FDA for safety, efficacy, or quality. The decision to prescribe compounded medications is an individualized clinical determination made by the treating provider based on the patient's medical history, current health status, and telehealth evaluation. Nextmeds does not manufacture or compound medications. Actual medication appearance may differ from website imagery.

Pharmacy Partners: Prescriptions are filled by independently owned and operated state-licensed 503A compounding pharmacies within the Nextmeds pharmacy network. Each pharmacy maintains its own state board of pharmacy licenses and operates under applicable federal and state compounding regulations.

Individual results vary based on starting weight, medical history, program adherence, diet, and exercise. The weight loss figures referenced on this website are based on self-reported data from Nextmeds members and are not derived from clinical trials or peer-reviewed studies. Not all members experience the same results. A prescription is never guaranteed and is at the sole discretion of the treating provider. Consult your healthcare provider before beginning any weight management program.

The Nextmeds healthcare membership includes access to telehealth consultations with licensed providers and, where clinically appropriate, prescription fulfillment through the Nextmeds pharmacy network. Medical services are provided by OpenLoop Healthcare Partners, PC and its affiliated professional medical practices, independently owned and operated. Nextmeds provides the technology platform and administrative services and does not provide medical services or make prescribing decisions. No data, photographs, claims, or other information presented on this website are derived from clinical trials or published peer-reviewed studies. All results and testimonials are representative of individual Nextmeds member experiences only.

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All medical services, including clinical evaluations, treatment planning, and prescribing decisions are provided by affiliated professional medical practices, which are independently owned and operated. Nextmeds provides the technology platform and administrative coordination services that connect you with your healthcare provider. Nextmeds does not provide medical services, does not employ healthcare providers, does not participate in clinical decisions, and does not practice medicine.

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