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BeYeRoyal Intake Form
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First name
(Required)
Last name
(Required)
Phone
(Required)
Email
(Required)
Shipping Address
(Required)
Birthday
(Required)
Month
Month
Day
Year
What was your sex assigned at birth?
(Required)
Male
Female
Do you currently take any medications?
(Required)
Yes
No
If yes, please include name, dose, and frequency of all medications. If no, enter NA.
(Required)
What is your current weight?
(Required)
What is your current height?
(Required)
Why do you want to lose weight?
(Required)
Improve overall health
Feel better about my body
Look my best for an upcoming event
All of the above
How much weight do you want to lose?
(Required)
20 lbs. or less.
21-50 lbs.
51+ 21-50 lbs.
Not sure yet
Does any of the following apply to you?
(Required)
Currently or possibly pregnant, or actively trying to become pregnant
Breastfeeding or bottle-feeding with breastmilk
End-stage kidney disease (on or about to be on dialysis)
End-stage liver disease (cirrhosis)
Current or prior eating disorder
Current suicidal thoughts and/or prior suicidal attempt
None of these apply to me
Are you currently taking or have recently (within the last 12 months) taken medication(s) for weight loss?
(Required)
Yes, I currently take or have recently (within the last 12 months) taken a GLP-1 medication for weight loss
Yes, I currently take or have recently (within the last 12 months) taken another medication for weight loss
No
Are you currently taking , plan to take, or have recently (within the last 3 months) taken opiate pain medications and/or opiate-based street drugs?
(Required)
Yes
No
Have you had prior bariatric (weight loss) surgery or any abdominal/pelvic surgeries?
(Required)
Yes
No
Please list all your bariatric (weight loss), abdominal, and pelvic surgeries. Please include date range and type of surgery.
(Required)
How would you describe your level of stress?
(Required)
I rarely feel stressed
I feel stressed a few times a week
I feel stressed all the time
On average, how much sleep do you get a night?
(Required)
More than 9 hours
7-9 hours
Less than 7 hours
If varies/I have trouble sleeping
Where do you hold most of your weight?
(Required)
Around my stomach or waist
Hips and thighs
All over
When it comes to cravings, what type of food do you usually go for?
(Required)
Sweet
Salty
Both
I don't have cravings
Which eating habit sounds most like you?
(Required)
I'm usually multitasking when I eat
I tend to snack when stressed
I turn to food for comfort
I often reward myself with food
I center my social life around dining out
Any additional areas you'd like your program to focus on?
(Required)
Realistic nutrition plan
Movement that works for you
Getting better sleep
Building healthier habits
All of the above
What would reaching your goal weight mean for you?
(Required)
Having more energy
Feeling more confident
Improving overall
Feeling better in my body
Feeling good in my clothes
Have you ever attempted to lose weight in a weight management program, such as through caloric restriction, exercise, or behavior modification?
Yes
No
Please provide brief details of your attempt to lose weight in a weight management program, such as through caloric restriction, exercise, or behavior modification
(Required)
Are you willing to
(Required)
Reduce your caloric intake alongside medication, if clinically appropriate
Increase your physical activity alongside medication, if clinically appropriate
All of the above
None of the above
How has your weight changed in the last 12 months?
(Required)
Lost a significant amount
Lost a little
About the same
Gained a little
Gained a significant amount
Have you been diagnosed with prediabetes or type 2 diabetes?
(Required)
Yes
No
What was your most recent fasting glucose value?
(Required)
What is your current or average blood pressure range?
(Required)
<120/80 (Normal)
120-129/<80 (Elevated)
130-139/80-89 (High Stage 1)
Unsure
What is your current or average resting heart rate?
(Required)
<60 beats per minute (Slow)
60-100 beats per minute (Normal)
101-110 beats per minute (Slightly Fast)
Unsure
Do you have any medication allergies?
(Required)
Yes
No
Please list your medication allergies and your reaction(s)
(Required)
Do you have any further information you would like the clinician to know?
(Required)
Select Your Program
(Required)
Semaglutide 6 Week Introductory Program
$
350
Tirzepatide 4 Week Introductory Program
$
400
Any Dose Semaglutide
$
350
Any Dose Tirzepatide
$
500
Priority Shipping (Required)
$
10.95
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