Medical Questionnaire, New Hope Weight Loss

Step 1: Conditions Requiring Review

Check all that apply. These answers require individual clinical review, and this online pathway may not proceed.

End-stage kidney disease (on or about to be on dialysis) End-stage liver disease (cirrhosis) Current suicidal thoughts Cancer, active diagnosis, active treatment, or in remission/cancer-free less than 5 years (excludes non-melanoma skin cancer cured via simple excision) History of organ transplant on anti-rejection medication Severe gastrointestinal condition (e.g., gastroparesis, inflammatory bowel disease) Current diagnosis of or treatment for an eating disorder (anorexia nervosa or bulimia nervosa) Personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia Syndrome Type 2 (MEN-2) Currently pregnant, breastfeeding, or planning to become pregnant within 2 months

None of these conditions apply to me

Immediate support is available

If you are having suicidal thoughts now or need emotional-crisis support, call or text 988, or use 988 Lifeline chat. Support is available 24/7 in the United States.

If you or someone else is in immediate physical danger or has a medical emergency, call 911 or go to the nearest emergency room.

This online weight-management pathway will not submit or continue while current suicidal thoughts are selected.

We're Unable to Proceed

This online pathway cannot continue with the selected response. Discuss appropriate care options with a licensed clinician. If you already paid, any refund is handled under our Refund Policy.

Checked a box by mistake? Uncheck it to continue. If you need help, call (657) 837-3342. Staff can explain the process and next steps; clinical eligibility is determined by a clinician.

Step 2: Additional Health History

Check all that apply. This information will be reviewed by our physician to ensure safe, personalized treatment.

None of these conditions apply to me

Step 3: Your Contact Information

Almost done. Confirm your contact details and add your shipping address. For your privacy, the quiz and this medical form are stored separately, so we ask again here.

First Name *

Last Name *

Date of Birth *

You must be at least 18 years old to use this form.

Email *

Phone *

Shipping / Mailing Address

Street Address *

City *

State used to confirm availability *

We use your state to confirm telehealth, prescribing, and pharmacy availability. Selecting a state does not mean that service is available there.

ZIP Code *

Next step after you submit: secure checkout for your one-time $119 physician review. Medication is separate (compounded semaglutide from $166/mo, tirzepatide from $233/mo) and is only charged if the physician prescribes it for you. Compounded medications are not FDA-approved and not brand-identical; results vary. HSA/FSA accepted; Cherry, Klarna, and Affirm financing available. See payment options.

By submitting, you agree to our Privacy Policy and HIPAA Notice, and consent to be contacted by our medical team.

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Questionnaire Submitted!

Your medical questionnaire has been submitted for physician review. Continue to secure checkout to complete your one-time $119 physician review. Medication is separate and is only charged if prescribed.

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Questions? Call (657) 837-3342