Weigh Loss Form

What do you want to accomplish with the yupMD Program?

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Loose Weight

Improve Health

Increase Energy

Other

Getting Started

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We can't wait to meet you.

Please fill in the details below so that we can get in contact with you.

Please enter your name

Please enter a phone number

Please enter your email

Contact Details

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Let’s start with where you are now

Use the sliders below to calculate your BMI

Your Age

Height

1000

Weight

50

Your BMI

$

BMI

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Are you pregnant, or trying to become pregnant?

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Yes!

No.

Pregnant?

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Are you breastfeeding?

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Yes!

No.

Breastfeeding?

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Do you have a history of diabetic retinopathy?

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Yes!

No.

History

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Have you been diagnosed with any conditions involving liver gallbladder or pancreas?

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Yes!

No.

Conditions

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Have you ever had any thoughts of self harm or severe depression?

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Yes!

No.

Mental Health

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Do you or any member of family have thyroid or pancreas cancer?

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Yes!

No.

Background

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Do you have any history of thyroid disease?

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Yes!

No.

History

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Have you ever had any organ removed?

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Yes!

No.

Surgery

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Are you on any other weight loss medication?

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Yes!

No.

Medication

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Confirm Submission.

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Confirmation

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What's your best contact email?

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