CPEP Weight Loss Intake CPEP Weight Loss Intake Personal Details Basic info Name* Age* Height (cm)* Current Weight (kg):* Goal Weight (kg)* Weight Loss Goals What is your main goal?* Lose WeightImprove HealthIncrease energyImprove fitnessOther How much weight would you like to lose?* Health Screening Do you have any of the following conditions?* Diabetes / blood sugar issuesThyroid problemsHeart disease / high blood pressureKidney or liver diseaseHormonal conditionsOther Are you currently taking any medications?* Select an option Yes No Have you used weight loss medications or peptides before?* Select an option Yes No Do you have a history of* PancreatitisGallbladder problemsMedullary thyroid cancer or MEN2None of the above Are you currently pregnant?* YesNo Are you currently breastfeeding?* YesNo Are you currently trying to conceive (planning to become pregnant)?* YesNo Do you have any of these weight-related conditions?* Type 2 diabetesHigh blood pressureDyslipidemiaSleep apneaOther verified obesity-related conditionsNone of the above Submit Assessment