Full Name
Date of Birth
Phone Number
Email Address
State of Residence
Height
Weight
Do you have a primary care provider?
YesNo
If yes, name & location
Have you had an A1c test in the past 6 months?
Most recent A1c value
Upload lab report (optional)
Is your A1c ≥ 5.7%?
If YES, select one 5.7–5.9% (Prediabetes)6.0–6.4% (High-risk Prediabetes)≥ 6.5% (Diabetes)
Has your A1c increased by ≥ 0.5% compared to your previous value? YesNoUnsure (upload labs)
Have you been diagnosed with Type 2 Diabetes (T2DM)? Yes (within last 3 months)Yes (longer than 3 months ago)NoUnsure
Have you recently been advised to start insulin? YesNoAlready using insulin
Type of insulin (if known)
Current dose (if known)
Are you currently taking or planning to start a GLP-1 medication? Yes – Starting soonYes – Currently takingNo
Which medication? MounjaroOzempicWegovyTrulicityZepboundOther
If “Other”, please specify
Current/starting dose
Have you used a CGM before? YesNo
Are you currently using or planning to start a CGM? Yes – StartingYes – Already have oneNo
CGM Type
Do you need help with setup? YesNo
Are you experiencing any of the following? Increased thirstFrequent urinationFatigueUnintentional weight changeBlurry visionNumbness/tingling in hands or feetNone of the above
Do you have any of the following conditions? High blood pressureHigh cholesterolThyroid diseasePCOSObesitySleep apneaNone
How would you describe your current diet? —Please choose an option—Standard American (fast food, processed foods)BalancedLow-carb / KetoHigh-proteinPlant-basedOther
How often do you exercise? Rarely1–2× per week3–4× per week5+× per week
Do you feel you need help with nutrition, grocery shopping, or meal planning? YesNo
Are you able to commit to consistent visits for 12 weeks? YesNoUnsure
Which services are you most interested in? (Select all) Lab monitoringWeekly provider visitsDietitian coachingMedication management (GLP-1, insulin, etc.)CGM monitoringWeight loss + metabolic health
Are you using insurance or self-pay for the program? InsuranceSelf-pay
Insurance provider (if applicable)
Do you have a deductible or high-deductible plan? YesNoUnsure
Please upload any relevant labs, medication list, or previous glucose readings.
945 Stockton Drive,Ste #6100 Allen, TX 75013
Phone: 972-390-7667
Fax: 972-390-1557
