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Date of birth
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Have you gained weight in the last 2 years?*
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Did you experience weight loss issues as a child?*
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Do you have a history of diabetes?*
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Do you have a history of hypertension?*
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Do you have a history of high cholesterol?*
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Have you had a gastric bypass?*
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Have you had a Gastric Band?*
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Do you have a history of Pancreatitis?*
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Do you have a history of Thyroid Cancer?*
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Do you have a history of Multiple Neoplasia 1 or 2 (Cysts on the endocrine glands)?*
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Sex Assigned At Birth (accuracy is important for medical/risk aversion precautions)*
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Do you have a history of PCOS (Poly-cystic ovarian syndrome)?*
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Is there a family history of (PCOS) Polycystic Ovary Syndrome - for women only*
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Are you currently pregnant or breast-feeding or do you plan to become pregnant?*
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Do you have a family history of diabetes?*
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Do you have a family history of heart disease?*
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Do you have a family history of obesity?*
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Is your billing address the same as your shipping address?*
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Is patient paying with a credit/debit card in his/her own name?*
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Please select the name of your advisor*
Socorro
Kayla
Liv
Jennifer
Phoebe Waits
Robin
Big Chip Trimble
Prestige Marketing USA
None of the above
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