Mochi Eligibility Form

Have you ever experienced a binge eating episode?

Eating large amounts of food even when not physically hungry

Eating alone because of embarrassment of how much one is eating

Feeling disgusted with oneself, depressed, or very guilty afterwards

Heart Condition (Heart Failure, Atrial Fibrillation, Arrhythmia, Valvular Defect, Brugada, Heart Attack, Prolonged QT)

Birth Control (IUD, pill-form, nexplanon, etc.)

Anti-depressant/Anti-anxiety (Lexapro, Zoloft, Celexa, Prozac, Paxil, Cymbalta) 

Blood Pressure medication (Lisinopril, Amlodipine, HCTZ, Valsartan, Atenolol, etc.)

Migraine medication (sumatriptan, rizatriptan, etc.)

ADHD medication (Methylphenidate, dextroamphetamine, etc.)

Benzodiazepine Sleep Aid (Zolpidem, Ativan, etc.)

Opiates (Fentanyl, Hydrocodone, Oxycodone, etc.)

Allergy/Asthma (Proair, Advair, Allegra, Flonase) 