CosmeticRx - Weight Loss Questions

Your body's ability to produce **Human Growth Hormone (HGH)** naturally declines with age.

This can lead to a decrease in **muscle mass**, **energy**, and **overall vitality**.

**Sermorelin** can help stimulate your body's own HGH production.

What is your primary goal with Sermorelin?

Improve muscle mass and body composition Increase energy and vitality Enhance recovery and sleep quality General anti-aging and wellness Other

Your goals are our priority.

To find a personalized plan for you, our physicians need you to build your Health Profile first.

Ready?

Please provide your height and weight.

Your height

Feet Inches

Your current weight

Pounds

Do you currently have, or have you ever been diagnosed with, any of the following heart or heart-related conditions?

Select all that apply.

Atrial fibrillation or flutter Tachycardia (episodes of rapid heart rate) Heart failure Heart disease, stroke, or peripheral vascular disease Prolonged QT interval Other heart rhythm issues or ECG abnormalities Hypertension (high blood pressure) Hyperlipidemia (high cholesterol) Hypertriglyceridemia (high triglycerides) No, I have not been diagnosed with any of these heart conditions

Do you currently have, or have you ever been diagnosed with, any of these hormone, kidney, or liver conditions?

Select all that apply.

Multiple Endocrine Neoplasia syndrome type 2 (MEN2) Personal history of thyroid cancer Family history of thyroid cancer Chronic kidney disease Diabetes requiring insulin Type 2 Diabetes Prediabetes and Insulin Resistance Fatty liver disease (NAFLD or NASH) Kidney stones Liver cirrhosis or end stage liver disease Hypothyroidism (low functioning thyroid) Hyperthyroidism (high functioning thyroid) Graves disease Other thyroid issues Syndrome of Inappropriate Antidiuretic Hormone (SIADH) No, I have not been diagnosed with any of these conditions

Have you ever been diagnosed with any of the following conditions?

Select all that apply.

Chronic candidiasis (fungal infection) Eating disorder Gout Lymphedema or chronic lower extremity swelling where other causes have been ruled out Metabolic syndrome Obstructive sleep apnea Osteoarthritis Tinea infections (skin folds) History of cancer No, I have not been diagnosed with any of these conditions

Have you had any of the following procedures or conditions related to your gastrointestinal health?

Select all that apply.

Bariatric surgery Pancreatitis History of delayed gastric emptying or gastroparesis Gallstones or other gallbladder issues GERD / Acid Reflux No, I have not been diagnosed with any of these conditions or procedures

Do you currently have an active cancer diagnosis or are you undergoing treatment for cancer?

No Yes

List any allergies that you have

Do you currently take any of the following medications?

Select all that apply.

Any form of growth hormone High-dose corticosteroids Opioids Oral estrogen (e.g., birth control pills or hormone replacement) Any medications for diabetes None of the above

List any other medications that you take.

Is there anything else you want your healthcare provider to know about your health?

Include any additional details about the conditions you've already reported.

No Yes

You've qualified for treatment

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