Section 1: BMI Information

1) What is your current height? (in feet): *

Inches *

2) What is your current weight? (in pounds): *

Note: A BMI calculator will be used to assess your BMI based on your height and weight.

Section 2: Comorbidities (Answer if your BMI is between 27 and 29.99)

3) Have you been diagnosed with hypercholesterolemia (Cholesterol > 240 mg/dL) or are you currently on medication for high cholesterol? (Yes/No) *YesNo

4) Are you currently on medication for hypertension? (Yes/No) *YesNo

5) Have you been diagnosed with Type 2 Diabetes Mellitus or Prediabetes confirmed by a blood test? (Yes/No): *YesNo

6) Do you have sleep apnea, and are you using CPAP therapy? (Yes/No) *YesNo

Section 3: Current Medications

7) Are you currently using any of the following medications? (Check all that apply)Insulin-dependent Diabetes medications (Type 1, select Type 2)Sulfonylurea medicationsGlibenclamideGliburonGlipizideGlimepirideGliclazideJanuvia (sitagliptin)Dilantin (used for seizure control)

If yes, please list medications here:

Section 4: Medical History

8) Have you had a history of pancreatitis? (Yes/No) *YesNo

9) Do you have a personal or family history of medullary thyroid cancer? (Yes/No) *YesNo

10) Do you have a personal or family history of Multiple Endocrine Neoplasia (MEN)? (Yes/No) *YesNo

Section 5: Continuation of Therapy (For existing GLP-1 users

11) Are you currently using GLP-1 therapy? (Yes/No) *YesNo

12) If yes, what is your current BMI?

Note: GLP-1 therapy must be discontinued if BMI falls below 24.

Eligibility Criteria Summary

BMI Standards:

BMI ≥ 30: Eligible.

BMI 27-29.99: Eligible only with at least one comorbidity (Questions 3-6).

BMI < 27: Not eligible.

Automatic Disqualifications

Certain medications (Question 7).

Medical history related to pancreatitis, medullary thyroid cancer, or MEN (Questions 8-10).

Continuation Rules for Current Users:

Therapy must be discontinued if BMI falls below 24 (Question 12).

Please submit your responses for review by a healthcare professional.

semaglutide Therapy Qualifying Questionnaire