Journi

What is your height and weight?

Feet Inches Weight (lb)

What is your goal weight?

Sex assigned at birth

MaleFemale

Date of birth

Select everything that applies. Select “None of these” only if no other choice applies.

Medication allergy details, if applicable

Taken opioid pain medication or opioid-based street drugs in the last three months?

NoYes

Have you had prior weight-loss surgery?

NoYes

Do you currently take prescription medication?

NoYes

List current medications, doses, and frequency, if applicable

Blood pressure range Average resting heart rate

Have you taken weight-loss medication within the last four weeks?

Yes, a GLP-1 medicationYes, a different medicationNo

Have you participated in a structured weight-management program?

NoYes

How do you feel about a gradual pace toward your goal?

That works for meI would prefer a faster paceI would prefer a slower pace

Select any topics you would like to discuss with a clinician.

Additional information (optional)

First nameLast name

Shipping state

EmailPhone number

I confirm that my answers are complete and accurate.I acknowledge the Privacy Policy and understand this information will be used for care review.

Approval required: clinical criteria, consent language, state availability, and the care-team workflow must be approved before launch.