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Goal + Medical History Form

Complete the goal section, then continue to your medical history.

Step 1 of 1
What is your weight loss goal?
Select one option.
What is your current height & weight?
Enter your height in feet & inches, and your weight in lbs.
Estimated BMI
Weight must be at least 100lbs.
You can’t move forward because your BMI is not up to 27 or higher.
What was your gender assigned at birth?
Select one option.
What is your date of birth?
Format: DD/MM/YYYY
Please enter a valid date in DD/MM/YYYY.
Where are you located?
Select your state.
What is your goal weight?
Must be at least 100 lbs.
Goal weight must be at least 100lbs.
Are you here to be evaluated for weight loss?
All responses will be evaluated by a board-certified physician. Medication may be prescribed for appropriate candidates.
Have you ever attempted to lose weight in a weight management program?
Examples may include caloric restriction through diet, exercise, or behavior modification.
Are you willing to increase your physical activity alongside medication?
Select one option.
Are you willing to reduce your caloric intake alongside medication?
Select one option.
Please select any symptoms you have experienced recently:
Our version of GLP-1s contains an additive that helps alleviate the following symptoms.
Please describe “Other” before continuing.
Adding vitamin B to GLP-1 Medications has been proven to help with multiple functions.
Please indicate the ones you are most interested in below:
Do you have any of the following?
These are considered co-morbidities of the American Board of Obesity Medicine. While you may not need to have one of these for treatment, your doctor would like to know.
What is your current or average blood pressure range?
Select one option.
What is your current or average resting heart rate range?
Select one option.
Please read the following about all GLP-1s.
Common Names (Alphabetical Order):
Liraglutide (Brand: Saxenda)
Semaglutide (Brands: Ozempic, Rybelsus, Wegovy)
Tirzepatide (Brand: Mounjaro)

How They Work:
Increasing insulin production from the pancreas.
Decreasing glucagon release after a meal.
Slowing gastric emptying, which helps you feel fuller for longer.

Efficacy:
GLP-1s have been shown to aid in weight reduction, particularly when combined with lifestyle modifications such as regular exercise and a reduced calorie intake.
Please explain why before continuing.
Have you undergone gallbladder removal or cholecystectomy in the past?
Select one option.
Please explain how and when before continuing.
Do you have a history of pancreatitis, type-1 diabetes, GI diseases such as Crohn's disease, or ulcers, diabetic retinopathy, medullary thyroid cancer, MEN-2 (multiple endocrine neoplasia syndrome type 2)?
Select one option.
Please clarify before continuing.
Do you have a history of ascites, cirrhosis, or decompensated liver disease?
Select one option.
Please explain how and when before continuing.
Do you have chronic kidney disease or a history of kidney diseases?
Select one option.
Please explain how and when before continuing.
Do you have a history of kidney failure, a solitary kidney, a kidney transplant, chronic renal failure or seen a kidney specialist for kidney related issues within the last 12 months?
Select one option.
Please specify your medical condition before continuing.
Are you currently taking any prescription medications for weight loss?
Select one option.
Please enter the medication and process before continuing.
Do you have a family history of MEN2 or medullary thyroid cancer?
Select one option.
Please explain how and when before continuing.
What are your known allergies or intolerances?
Select one option.
Please describe your allergies/intolerances before continuing.
Do you have any medical conditions we should know about?
Select one option.
Please describe your condition before continuing.

Thank you for filling the form.

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RQ by Resenxia™ — Intake + Safety Questionnaire

This form helps our clinical team confirm eligibility, identify safety risks, and tailor monitoring. It does not replace medical care. If you have severe symptoms, seek urgent care.

1 Consent + Contact
2 Eligibility Snapshot
3 Medical History
4 Lifestyle + Readiness
5 Safety + Labs + Goals

Section 1 — Consent & Contact

Preferred contact method*

Consent confirmation*

“I confirm the information I provide is accurate to the best of my knowledge.”

Patient identity details*

Sex / Gender*

Location & phone*

Contact email & daily schedule*

Please complete this question before continuing.

Section 2 — Eligibility Snapshot

Body size baseline*

Provide accurate height and weight for safe dosing and realistic expectations.

Waist size & BMI awareness*

Main reason for starting Resenxia Slim™*

Previous weight-loss medicines*

Details of any previous medicines

Please complete this question before continuing.

Section 3 — Medical History (High-Value Safety Screen)

Answer carefully. If unsure, choose “Not sure”.

Cardiometabolic Conditions

Please complete all required fields before continuing.

Section 4 — Lifestyle + Readiness

Lifestyle factors*

Symptoms to Track (Baseline)

Select all that apply*

Tirzepatide Readiness

Please complete this question before continuing.

Section 5 — Safety Education Check (Required)

Confirm you understand key safety messages*

Baseline Measurements & Labs

Goals, Success Metrics, Preferences

Please complete this question before submitting.

By submitting, you confirm the information is accurate to the best of your knowledge. Your responses are treated confidentially and used for clinical assessment and follow-up.

Submission received
Proceed to checkout to complete your order.

Next Step: Payment

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If you have updates after submitting, contact:
📧 resenxiabiohealth@gmail.com · 📱 WhatsApp: 0704 777 9763

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