GLP-1 Eligibility Assessment

Let's start with the basics

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~3 min

First name * First name is required

Last name * Last name is required

Email address * We'll use this to send your assessment results Please enter a valid email

Phone number (optional)

Date of birth * Date of birth is required

State * Please select your state

Your health profile

Helps your physician determine the right starting dose.

Current weight *

lbs

Current weight is required

Goal weight *

lbs

Goal weight is required

Height *

ft in

Please enter your height

—

BMI Your body mass index

Medical history

Check all conditions that apply to you currently or in the past. This helps your doctor make safe prescribing decisions.

Type 2 diabetes or pre-diabetes Heart disease or hypertension Thyroid disorder History of eating disorders Currently pregnant or breastfeeding Kidney disease Pancreatitis Family history of medullary thyroid cancer (MTC) None of the above

Save your progress (optional) We'll save your spot and email your results if you don't finish now.

GLP-1 experience

Your medication history helps your doctor avoid restarting a treatment that didn't work for you.

Have you previously used a GLP-1 medication? *

Yes No

Please select an option

Which medication did you use?

Why did you stop?

Your goals

Understanding your motivation helps us match you with the right physician and approach.

What's your primary goal? * Please select a goal

How long are you committed to this journey? * Please select a timeline

Review & consent

Please read and acknowledge the following before submitting your assessment.

This is not a medical consultation. The information you provide will be reviewed by a licensed physician who will determine whether you may be a candidate for treatment. Submitting this form does not establish a patient–physician relationship and does not guarantee a prescription.

Treatments described are FDA-approved medications only. PropPilot does not prescribe or recommend unapproved compounded versions of any medication.

By submitting, you agree to PropPilot's Telehealth Consent, Privacy Policy, and Terms of Service.

I have read and agree to the Telehealth Consent, and I confirm the information I provided is accurate to the best of my knowledge.

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No charge unless approved