Black Wolf Fitness • Pre-screening

Basic Information

Tell us a little about yourself. We’ll calculate your BMI as part of the intake.

Gender

Height (feet)

Height (inches)

Weight (pounds)

Age (years)

BMI

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Enter height & weight

Your BMI is one factor a provider or coach may review.

Medical Survey

If you’re not sure on any item, choose “Yes / not sure” so a provider can review your history.

Personal or family history of medullary thyroid carcinoma (MTC) or MEN2?

Yes / not sure

History of severe reaction (anaphylaxis or angioedema) to GLP-1 medications?

Yes / not sure

Currently pregnant, trying to become pregnant, planning pregnancy soon, or breastfeeding?

Yes / not sure

History of pancreatitis diagnosed by a medical provider?

Yes / not sure

Currently treated for type 2 diabetes with insulin?

Yes / not sure

Taking type 2 diabetes medications (e.g., glipizide, glyburide, Jardiance, etc.)?

Yes / not sure

Contact & Verification

We only use this info to coordinate your consult and onboarding—no spam.

Name

we don't spam you

Phone

I have a valid U.S. government-issued ID.

I have a valid U.S. shipping address.

Next Steps

This is an educational and administrative intake only. It is not medical advice, does not diagnose or treat any condition, and does not create a provider–patient relationship. Only a licensed medical provider can determine whether any medication is appropriate for you.