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Health/Weight Questionnaire

Please fill out the following form.

First name

Last name

Email*

Date of birth

Month

Day

Year

Weight*

Height*

What are your primary health or wellness goals?

Weight Loss

Hormone Balance

Energy/Fatigue Improvement

Anti-aging/Longevity

Mental clarity/mood

Body Composition/Build Muscle

Sex Drive/Libido

Skin and Hair Improvement

Other

Do you have any personal or family history of any of the following conditions? (Check all that apply)*

Medullary Thyroid Cancer (MTC)

Mutliple Endocrine Neoplasia Syndrome Type 2 (MEN 2)

Gallbladder Disease

Severe Gastrointestinal

Pancreatitis

Cancer (Past or Present)

Kidney Disease

Pituitary Deficiencies

None of the above

Other

Are you currently pregnant and/or breastfeeding?

Yes

Are you currently taking any prescription medications? (If yes, please list)

Do you have any chronic medical conditions? (e.g. diabetes, hypertension, PCOS, hypothyroidism)*

What are you interested in discussing? GLP-1; Peptides; Both

Have you tried other weight loss methods in the past? (e.g. diet, exercise, medications, programs — please list)

How did you hear about The Guided Body?

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I declare that the information I have provided is true, accurate, and complete to the best of my knowledge.

Get in Touch

Interested but have questions? Don't hesitate to ask. Contact me here.

We are here to guide you on your journey to a healthier you. Contact us today to start your personalized weight loss and/or wellness program.

First name*

Last name*

Email*

How can I help you?*

The Guided Body LLC

Teresa Pelayo, FNP-C
Founder & Medical Provider

Email: Teresapelayo@theguidedbody.com

Please note: At this time, we are only able to provide care to patients who are residents of the state of Florida.

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Health/Weight Questionnaire

Get in Touch

Teresa Pelayo, FNP-C Founder & Medical Provider

Teresa Pelayo, FNP-C
Founder & Medical Provider