Optimal Direct
Home
Why Choose Optimal Direct
How It Works
Programs
FAQ
Contact Us
Home
Why Choose Optimal Direct
How It Works
Programs
FAQ
Contact Us
Intake Form →
Ready to Begin?
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 2
Name
*
First
Last
Email
*
Phone
Date of Birth
Biological Sex
Male
Male
Female
Prefer not to say
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
State
What is your goal weight?
Name of your Primary Care Provider (MD, NP, PA) (include the practice name if known)
Name
Phone
Next
Please list your current Medications,dose, directions: (include OTC and supplements) (example: HCTZ, 25mg, 1 tab daily)
Do you have any allergies to medications?
*
Yes
No
Enter allergies medications
Have you been to a Weight Loss Clinic in the past 3 months? If so, please list the name of the clinic attended?
*
Yes
No
Enter Name of the clinic
Please list use (current or previous) of appetite suppressants, injections, or other means of weight loss:
Please answer the following:
Use of tobacco and amount:
Use of alcohol and amount:
Use of illegal drugs and amount
Use of Adderall or similar stimulant medications
Amount of caffeine and type/frequency
Exercise: type/duration/frequency:
Have you ever been told by a doctor to follow a specific nutrition plan (diabetic, low cholesterol, heart healthy etc.)?
*
Yes
No
Are there certain foods that you avoid from your diet?
Yes
No
If yes, please describe:
Do you have Diabetes?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you have any kidney problems?
*
Yes
No
Do you have a personal or family history of Thyroid Cancer?
*
Yes
No
Do you have a personal or family history of Pancreatic Cancer?
*
Yes
No
Do you have personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)?
*
Yes
No
Do you have a history of slow gastric emptying or severe constipation that resulted in a medical procedure?
*
Yes
No
Are you a patient at a Pain Clinic?
*
Yes
No
Are you now, or could you be pregnant?
*
Yes
No
What is your method of Birth Control?
Have you been diagnosed with Thyroid disease?
*
Yes
No
Have you had Bariatric Surgery?
*
Yes
No
Any diagnosis of heart arrhythmia or heart murmur? If so, please provide detail:
Any history of heart attack or stroke? If so please list the year it occurred and any details:
Please list any chronic medical conditions: (examples: high blood pressure, arthritis, IBS)
What are the top 2 obstacles you face when trying to lose weight?
Success is measured by more than a number on the scale. How do you define weight loss success? Please choose all that apply:
*
Decrease in pounds / lower number on scale
Decrease in waist measurement
Less fatigue
Increase in confidence
Positive Outlook
Feeling empowered
Becoming more activity
Being more social
Other
Is there anything you want to share that could help us in taking care of you on this journey?
*
Are you currently pregnant, planning to become pregnant, or breastfeeding? (If male, please select N/A)
*
Yes
No
N/A
Height & Weight
Feet
*
Inches
*
Weight (lbs)
*
Have you used GLP-1 medications or any other prescription weight-loss drugs in the past 45 days?
*
Yes
No
Examples: Semaglutide, Tirzepatide, Mounjaro, Wegovy, Ozempic, Phentermine, Contrave, etc.
When was the last time you had an in person medical evaluation?
*
Less than a year ago
1 to 2 years
More than 2 years ago
Have you had any lab tests completed within the last 6 months that you’d like to share with your provider?
*
Yes
No
Labs are not required, but they can give your provider a more complete view of your health.
Please provide your lab test reports details
Monthly Subscription
*
Price:
$ 369.00
Pay Now
