Medical intake

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Section 1 of 8

Let’s start with the basics

Which state are you located in right now?

Date of birth Sex assigned at birth

We ask about sex assigned at birth because it affects medication safety questions, such as pregnancy.

Height and weight

Height Current weight (lb)

Goal weight (lb)

BMI: —

Weight history and related conditions

Highest adult weight (lb)

Have you been diagnosed with any of these? Select all that apply.

High blood pressure High cholesterol or triglycerides Prediabetes or insulin resistance Type 2 diabetes Obstructive sleep apnea Polycystic ovary syndrome (PCOS) Fatty liver disease Heart disease None of these

What have you tried before? Select all that apply.

Diet changes Exercise program Commercial weight-loss program Prescription weight-loss medication Nothing yet

Safety screening

These questions help your provider decide whether GLP-1 medication is safe for you. Select all that apply to you now or in the past.

Personal or family history of medullary thyroid cancer, or Multiple Endocrine Neoplasia type 2 (MEN 2) Pancreatitis Type 1 diabetes Gallbladder disease or gallstones Gastroparesis or severe digestive disease Diabetic retinopathy Kidney disease Liver disease other than fatty liver Weight-loss surgery Anorexia or bulimia, now or in the past Depression, or thoughts of self-harm in the past year None of these

Pregnancy and contraception

Do any of these apply? Select all that apply.

Currently pregnant or might be pregnant Currently breastfeeding Planning pregnancy in the next 3 months Using oral birth control pills None of these

No questions in this section apply to you. Continue to the next section.

Medications and allergies

Are you currently taking, or have you taken, a GLP-1 medication? Which medication, current dose, and date of last dose? Do you take insulin or a sulfonylurea (such as glipizide or glyburide)? All other current medications and supplements Medication allergies How many alcoholic drinks do you have in a typical week?

Recent vitals and labs

Recent blood pressure (optional) Resting heart rate (optional)

Have you had blood work in the last 12 months? Do you have a primary care provider? Anything else your provider should know? (optional)

Treatment preference and attestation

Medication preference

Your preference is shared with your provider, who makes the final decision.

I confirm that the information I provided is accurate and complete to the best of my knowledge. I understand that inaccurate information can affect my safety. I have read and agree to the Telehealth Consent and acknowledge the Important Safety Information.

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Aldwyn

Mount Climb LLC 10869 N Scottsdale Rd, #103-748
Scottsdale, AZ 85254 support@aldwynhealth.com +1 (337) 382-8330 Care team: Mon–Fri, 9am–6pm MST

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Compounded semaglutide
Compounded tirzepatide
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Aldwyn is operated by Mount Climb LLC, which provides administrative and technology services only and does not practice medicine or pharmacy. Medical services are provided by independent, US-licensed healthcare providers, who exercise independent clinical judgment. Prescriptions are filled by state-licensed US pharmacies licensed to dispense in each state we serve. A prescription is issued only after a licensed provider completes an evaluation, and payment does not guarantee that a medication will be prescribed or dispensed. Services are available only in the states listed on our Where we operate page. This site is an advertisement for telehealth services.

Compounded drugs are not approved by the FDA, and the FDA does not review them for safety, effectiveness, or quality before they are dispensed. Compounded medications are not generic versions of any FDA-approved drug. Aldwyn does not compound or dispense medication. Individual results vary.

Photography is for illustration; people shown are models. Photos courtesy of Unsplash.