GLP-1 Metabolic Wellness Program by GraceMed

How can we help?

Select all that may be of interest to you.

All programs include a Weight Loss focus with GLP-1 Therapy.

GLP-1 Weight Loss Therapy

(and keeping it off!)

Nutritional/ Diet Coaching

+ GLP-1 Weight Loss

Mind Coaching

+ GLP-1 Weight Loss

Strength Training Coaching

+ GLP-1 Weight Loss

Give me the works!

I would love help with it all

How would you describe your diet in the past month?

Understanding your diet helps us choose the right treatment for you.

very healthy

somewhat healthy

neither healthy or unhealthy

somewhat unhealthy

very unhealthy

Which level of activity best describes your lifestyle?

"Active" can mean any kind of activity, from standing, to high-intensity workouts.

very active

somewhat active

not very active

How long have you had concerns about your weight?

Understanding if there’s been a recent change will help us make an accurate diagnosis.

Less than 6 months

6-12 months

1-5 years

More than 5 years

What is your goal or ideal weight?

(SLIDE to select desired goal weight)

100lbs 300lbs

Have you ever been at your goal weight as an adult?

Yes

No, but this time will be different!

Great start! 💪

Let's keep going.

This information is helping us build your Personalized Treatment Plan.

Does your weight negatively affect your physical or mental health?

Yes, a lot

Yes, somewhat

Not too much

Not at all

Are you currently affected by an eating disorder?

No, but I have been in the past

Yes

Was your eating disorder diagnosed by a healthcare provider?

Yes

Tell us more about your experience with eating disorders

Please specify an answer

Have you had blood work done in the last 6 months?

Yes

What was your most recent blood pressure reading?

Your blood pressure helps us determine if certain medications are safe for you.

Normal or Low (120/80 or lower)

Above Normal (121/80 to 129/80)

High (130/81 to 139/89)

Higher (140/90 or higher)

I don't know

Are you pregnant or breastfeeding?

Yes, I am currently pregnant

Yes, I am currently breastfeeding

Have you had any of the following surgical procedures?

Tap all that apply

Gastric sleeve

Gastric bypass surgery

Any other gastrointestinal surgery

NONE APPLY TO ME

Awesome! 👍

Thanks for providing us with the info so far.

With each response it helps us customize our approach for you.

What is the best contact information to send your Personalized Treatment Plan

Email address

Please enter a valid email address

What is your height & current weight?

We’ll use this to determine your Body Mass Index (BMI) for diagnosis. Remember, BMI is a measure of size – not health.

How tall are you?

Feet

3' 6'

Inches

0" 11"

What is your current weight?

lbs

Please specify an answer

How did you hear about us?

Facebook / Instagram

Google

Friends & Family

Physician Referral

Other

Are you interested in learning more about our monthly payment options?

Yes please!

No thanks, I intend to pay in full, up front

Unsure/ Undecided

Hang tight...

We are just getting ready to book your

FREE VIRTUAL CONSULTATION! 🚀

🎉 Great news! 🎉

Based on your responses

our Medical Team sees you

as a potential candidate for the program.

The next step in the process will be to book you a

FREE VIRTUAL CONSULTATION

to finalize your Treatment Plan and get you started.

Schedule your FREE Virtual Consultation

Our weight loss program isn’t a good match for you at the moment.

Your safety is most important to us, and, unfortunately, our program doesn’t work well for people with certain health conditions. Please consult your family doctor or visit a local walk-in clinic to go over weight management options that may work for you and your needs.

We’re sorry—our weight loss program isn’t a good match for you at the moment.

If you’re struggling with an eating disorder, you can reach the National Eating Disorder Information Centre (NEDIC) helpline at 1-866-633-4220 or use their online chat whenever you need.

Need additional care?

We are happy to help support with you by making a referral to a professional we trust. Please click the button below to access help now.

Sorry, our weight loss program is only available to those 18 years of age and older.

Your safety is most important to us, and, unfortunately, our program is not designed for those 18 years of age and younger. Please speak with a parent or guardian about what options might be best for you.

If you are suffering from an eating disorder, we are here to help.

Please complete the form below and we will connect you with a trusted professional that can help.

First Name

Please enter your first name

Last Name

Please enter your last name

Email address

Please enter a valid email address

Government Issued Health Card

Please provide images of the front and back of your provincial photo health card

FRONT

Click here to load camera or attach image

Accepts png, jpeg, pdf

BACK

Click here to load camera or attach image

Accepts png, jpeg, pdf

Tips on uploading your ID

Esnure the photo is clear and well-lit.

Ensure the ID isn't cut off in the photo.

Double check that your ID isn't expired.

How GraceMed secures information collected

Your ID photos will be kept confidential and only used to confirm your identity.

GraceMed uses secure SSL encryptions to ensure your information is safe.

Your data is never shared with 3rd parties.

How can we help?

Select all that may be of interest to you.

All programs include a Weight Loss focus with GLP-1 Therapy.

How have you tried to lose weight in the past?

Select all that apply

How would you describe your diet in the past month?

Understanding your diet helps us choose the right treatment for you.

Which level of activity best describes your lifestyle?

"Active" can mean any kind of activity, from standing, to high-intensity workouts.

How long have you had concerns about your weight?

Understanding if there’s been a recent change will help us make an accurate diagnosis.

What is your goal or ideal weight?

(SLIDE to select desired goal weight)

Have you ever been at your goal weight as an adult?

Great start! 💪

Let's keep going.

This information is helping us build your Personalized Treatment Plan.

Does your weight negatively affect your physical or mental health?

Are you currently affected by an eating disorder?

Was your eating disorder diagnosed by a healthcare provider?

Have you had blood work done in the last 6 months?

What was your most recent blood pressure reading?

Your blood pressure helps us determine if certain medications are safe for you.

Do any of the following apply to you?

Select all that apply

Are you pregnant or breastfeeding?

Have you had any of the following surgical procedures?

Awesome! 👍

Thanks for providing us with the info so far.

With each response it helps us customize our approach for you.

What is the best contact information to send your Personalized Treatment Plan

What is your height & current weight?

We’ll use this to determine your Body Mass Index (BMI) for diagnosis. Remember, BMI is a measure of size – not health.

A few final questions before we can finalize your Personalized Treatment Plan.

How did you hear about us?

Are you interested in learning more about our monthly payment options?

Hang tight...

We are just getting ready to book your

FREE VIRTUAL CONSULTATION! 🚀

🎉 Great news! 🎉

Based on your responses

our Medical Team sees you

as a potential candidate for the program.

The next step in the process will be to book you a

FREE VIRTUAL CONSULTATION

to finalize your Treatment Plan and get you started.

Schedule your FREE Virtual Consultation

Our weight loss program isn’t a good match for you at the moment.

Your safety is most important to us, and, unfortunately, our program doesn’t work well for people with certain health conditions. Please consult your family doctor or visit a local walk-in clinic to go over weight management options that may work for you and your needs.

We’re sorry—our weight loss program isn’t a good match for you at the moment.

If you’re struggling with an eating disorder, you can reach the National Eating Disorder Information Centre (NEDIC) helpline at 1-866-633-4220 or use their online chat whenever you need.

Need additional care?

We are happy to help support with you by making a referral to a professional we trust. Please click the button below to access help now.

Sorry, our weight loss program is only available to those 18 years of age and older.

Your safety is most important to us, and, unfortunately, our program is not designed for those 18 years of age and younger. Please speak with a parent or guardian about what options might be best for you.

If you are suffering from an eating disorder, we are here to help.

Please complete the form below and we will connect you with a trusted professional that can help.

Rate the following statements...

Do you experience nausea or vomiting?

Do you experience diarrhea?

Do you experience constipation?

Do you experience bloating?

Do you experience heartburn/reflux?

Do you experience disrupted sleep?

Do you experience anxiety?

Do you experience depression?

Do you experience menstrual irregularities (skipped, frequent or heavy periods)?

Do you experience fatigue during the day?

Do you fixate on food?

Do you work-out (strength training)?

Do you eat junk food?

Do you drink sugary drinks like soda or juice?

Do you use infrared light therapy?

Do you use infrared sauna therapy?

Do you use pulsed electromagnetic field therapy (PEMF)?

Have you had a lot of stress in your life?

Just a few more questions...this time about your habits...

Do you smoke cigarettes or vape?

Do you use Marijuana?

Do you use 'street drugs'?