Online Prescription Assessment

Personal Details

1. Name

2. What is your biological sex?

3. Address

4. What is your date of birth?

5. What is your height?

6. What is your weight

7. Dosage of medication

Medication prescribed by US Doctor

8. Reason for requiring medication

9 Name of the prescribing doctor?

10. Have you used this medication before?

11. Are you taking any other medication?

12. Do you suffer from any other conditions?

13. Are you allergic to any substances, any medicine or food products?

14. BMI (If known)

15. Upload original RX

jpg, png, pdf file supported

16. Do you have Type 1 diabetes mellitus?

17. Do you have any history of medullary thyroid cancer?

18. Do you have history or family history of endocrine neoplasia?

19. Do you have any history of pancreatitis?

20. Do you have any liver or kidney impairment?

21. Do you have any history of gastrointestinal illness such as gateoparesis or malabsorption?

22. Are you pregnant or breastfeeding?

23. Do you have any history of diabetic retinopathy (diabetes eye disease involving retina)?