Patient Information
Question 1
Patient full name
Auto-populates the prescription PDF.
Question 2 *
Date of birth
Enter your date of birth in any common format — e.g. 06/15/1985, 6-15-1985, June 15 1985, or 1985-06-15.
Not Eligible: GLP-1 medications are approved for adults 18 and older only.
Question 3 *
Biological sex / gender
Question 4 *
Height and weight
Used to calculate BMI for medication eligibility.
Height
ft
in
Weight
Question 5
Mailing address
Street Address
City
State
ZIP Code
Question 6
Phone number
Health Profile
Question 7 *
Primary treatment goal
Question 8 *
Type 2 diabetes diagnosis?
Question 9
Injection preference
Most GLP-1 medications are weekly injections. Rybelsus is an oral pill option.
Question 10
Previous GLP-1 medication use?
Side effect history noted — we'll recommend a different GLP-1 mechanism for better tolerability.
Safety Screening
Question 11 *
Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN2)?
Contraindication: GLP-1 receptor agonists are contraindicated with personal or family history of MTC or MEN2. All GLP-1 medications are excluded.
Physician Review Required before starting any GLP-1 medication. Please discuss your thyroid/endocrine family history with your doctor.
Question 12 *
History of pancreatitis or severe gallbladder disease?
Contraindication: History of pancreatitis is a contraindication for GLP-1 therapy.
Note: GLP-1 medications may increase gallbladder risk. Physician review recommended before starting.
Question 13 *
Currently pregnant, breastfeeding, or planning pregnancy in the next 6 months?
Contraindication: GLP-1 medications are not recommended during pregnancy or breastfeeding.
Question 14 *
Diagnosed with Type 1 diabetes or diabetic ketoacidosis (DKA)?
Not Indicated: GLP-1 receptor agonists are not approved for Type 1 diabetes or DKA treatment.
Question 15 *
History of gastroparesis or severe GI motility disorder?
Contraindication: Gastroparesis is a contraindication for GLP-1 therapy due to further slowed gastric emptying.
Question 16
Additional health conditions or medications
Optional — helps refine your recommendation.
Payment Preference
Question 17
How would you like to pay for your medication?
Medication cost and fulfillment are handled separately by the licensed pharmacy you choose. A $75 prescription fee covers provider review and a signed prescription.
💊 Off-Label GLP-1 Screening Results
Screening Complete
Based on your responses, here is a summary and your eligible medication options. Click "Generate Rx PDF" on any medication to create an unsigned prescription for physician signature.
Medical Disclaimer: This screening tool is for informational purposes only and does not constitute medical advice, diagnosis, or treatment. Some uses discussed may be off-label and are not included in FDA-approved product labeling. All GLP-1 medications require a valid prescription from a licensed healthcare provider. Prescriptions generated by this tool are unsigned drafts for provider review and manual signature. Prices shown are general estimates subject to change and are not tied to a specific pharmacy. Always consult your healthcare provider before starting, stopping, or changing any medication.