Shape U Health

1
Are you currently, or were you recently, on a GLP-1 medication?* This field is required.Your response helps us make safe and appropriate medical decisions. Inaccurate information may increase your risk of side effects or complications.
Yes, I'm actively taking a GLP-1
I'm not actively taking a GLP-1, but have within the last 12 months
No, I have never taken a GLP-1
2
What is your current height and weight?
3
What state do you live in?* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
4
Do you have any of the following medical conditions?* This field is required.Select all that apply
Heart failure, stage 3 or 4 (EF level less than 50%)
Active cancer currently being treated
Currently pregnant or breastfeeding
Serious active mental health conditions (Such as active psychosis, suicidal thoughts, bipolar I, or schizophrenia)
None of the above
5
Has anyone in your immediate family ever been diagnosed with any of the following?* This field is required.Select all that apply
Multiple endocrine neoplasia type 2 (MEN2)
Medullary thyroid cancer (MTC)
None of the above
6
Have you been diagnosed with any of the following?* This field is required.Select all that apply
Multiple endocrine neoplasia type 2 (MEN2)
Medullary thyroid cancer (MTC)
Pancreatitis
Significant GI Issues (Such as gastroparesis, chronic constipation, or diarrhea)
None of the above
7
Would you be interested in a custom plan designed to help lower your risk of side effects like nausea, vomiting, and diarrhea?* This field is required.
Yes
No
8
Would you be interested in a custom plan designed to help lower your risk of muscle loss?* This field is required.
Yes
No
9
Name* This field is required.
First Name
Last Name
10
Birth Date* This field is required.
Date
Month
Day
Year
11
Gender* This field is required.
Female
Male
12
Email* This field is required.
example@example.com
13
Phone Number* This field is required.
14
Terms and Conditions* This field is required.
15
Signature
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16
Application Fee* This field is required.Our licensed healthcare provider will review your form, and get back to you by the next business day.
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