Weight Health Screening

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Tirzepatide

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Semaglutide

Discover weight loss plans tailored to your needs. We take the time to learn about you, your habits, and your health history to ensure you have an attainable plan.

Let's start with your name.(Required)

First Last

And your email?(Required)

What is the best number to reach you?(Required)

Consent(Required)

I agree to receive automated updates and promotional texts from Regenics at this number. Consent is not required for purchase. Msg & data rates may apply. Reply STOP to opt out. View our Privacy Policy and Terms.(Required)

Is this treatment for you or someone else?(Required)

Myself

Someone else

Hidden

Consent(Required)

This intake pertains to the patient. If you are assisting someone else, please answer the questions with the patient's information and history.

We want to make it easy on you. Which consultation method would you prefer?(Required)

An Online Questionnaire Consultation (Fastest, no additional consultation needed)

A Phone Consultation

Ideally, how much weight would you like to lose?(Required)

1-15 lbs

16-50 lbs

More than 50 lbs

Undecided, I just need to lose weight.

Losing weight has never been so easy – and it doesn’t require restrictive diets.

To create a custom plan for you, let’s start by building your weight loss profile.

Let's pair you with a licensed provider in your state. What state do you live in?(Required)

Consent(Required)

I agree to the Terms and Conditions and Telehealth Consent and I acknowledge the Privacy Policy.(Required)

Next, we will need to verify your eligibility. What is your date of birth?(Required)

Month

Day

Year

What is your height? Required

Feet(Required)

Inches(Required)

What is your current weight in pounds?(Required)

Please enter a number greater than or equal to 100.

What is your desired weight in pounds?(Required)

Is your current weight the most you have ever weighed?(Required)

Yes

Please include only your highest non-pregnant weight in pounds.

What is the most you have ever weighed?(Required)

Please enter your highest weight in pounds (lbs). This information will help a provider determine the best treatment for you.

What steps did you take to lose weight to achieve your current weight?(Required)

I followed a diet program with a medical provider or dietician

I used a weight loss medication

I tried exercising

Other

What other step did you take to lose weight to achieve your current weight?(Required)

What weight loss medication(s) have you used?(Required)

Tirzepatide (Mounjaro, Zepbound or compounded)

Semaglutide (Ozempic, Wegovy or compounded)

Orlistat: Also known as Xenical or Alli

Phentermine-topiramate: Also known as Qsymia

Naltrexone-bupropion: Also known as Contrave

Liraglutide (Victoza, Saxenda)

Phentermine

Metformin (Glucophage, Riomet, Glumetza, Fortamet)

How long did it take you to lose weight to achieve your current weight?(Required)

3-6 months

6-12 months

12 months or longer

What was your sex assigned at birth?(Required)

Female

Male

Are you currently pregnant or trying to become pregnant?(Required)

Yes, I am currently pregnant or trying to become pregnant

Are you currently breastfeeding?(Required)

Yes

Are you experiencing or have you ever experienced any of the following symptoms?(Required)

Frequently eating very large amounts of food and feeling like you can’t stop eating

Causing yourself to vomit in order to lose weight

Severely limiting the amount of food you eat due to an intense fear of gaining weight

None of these

Have you been diagnosed with any of the following conditions?(Required)

Anorexia

Bulimia

Binge eating disorder

None of these

Have you been in remission from your anorexia or bulimia eating disorder for one year or more?(Required)

No, I am currently being treated

No, I have been in remission for less than one year

Yes, I have been in remission for one year or more

Have you been in remission from your binge eating disorder for one year or more?(Required)

No, I am currently being treated

No, I have been in remission for less than one year

Yes, I have been in remission for one year or more

Are you currently receiving psychotherapy treatment?(Required)

Yes

Have you purged or forced yourself to vomit in order to lose weight within the last 12 months?(Required)

Yes

How frequently have you purged or vomited to lose weight over the last 3 months?(Required)

About once a week

About once a month

Not at all

Please be aware that purging (self-induced vomiting with or without the use of laxatives or diuretics/water pills), severely restricting your calories, or falling below a BMI of 18.5 (underweight) at any time while using a weight loss medication can increase your risk of electrolyte imbalance and potential for seizures. If you begin purging or severely restricting at any time while on treatment, please alert our Care Team and your primary care provider so that appropriate modifications to your treatment plan can be made to ensure your safety and continued success on your weight loss journey.(Required)

I understand, continue.

Have you been diagnosed with a mental health condition?(Required)

Yes

We ask this so your provider can have a complete understanding of your medical history so they can decide what is the best treatment for you.

Have been diagnosed with any of the following?(Required)

Depression

Generalized anxiety

Bipolar disorder (manic depression)

Panic attack

Psychiatric hospitalization within the last 3 months

Borderline personality disorder

Psychosis

Schizophrenia or schizoaffective disorder

Other

What other mental health condition have you been diagnosed with?(Required)

Are you currently taking any mental health medication to treat your condition(s)?(Required)

Yes

Please list the mental health medication(s) you are taking.(Required)

Include exact names of any medicines (e.g. Bupropion, Sertraline, Escitalopram)

Do you currently have any desire to harm yourself or others?(Required)

Yes

We ask this question so your provider can have a complete picture of your current health and determine which treatment might be right for you.

If you are experiencing suicidal thoughts and need to speak to someone, please reach out to individuals in your current environment or use the resources below for immediate assistance: 24/7 National Suicide Prevention Lifeline: 988 (call or text) En Español: 1-888-628-9454 24/7 Crisis Text Line: Text “HOME” to 741-741(Required)

I understand

Do you have any medical conditions or chronic diseases?(Required)

Yes

Be sure to include any conditions impacting your blood pressure, heart, or liver, and any diseases such as diabetes, cancer, or gout. It's important for your provider to have a complete understanding of your medical history so they can decide what is the best treatment for you.

Do you have a history of chronic kidney disease (CKD) or chronic renal disease?(Required)

Yes

Have you been diagnosed with any of the following?(Required)

Hypertension (high blood pressure)

Hypotension (low blood pressure)

Diabetes (Type 1)

Diabetes (Type 2)

Prediabetes

Kidney stones

Seizure disorder (including Epilepsy

Heart attack

Heart disease

Hyperlipidemia (high cholesterol)

Angina

Congestive heart failure

Liver issues

Cancer

Glaucoma

Gout

Cystic fibrosis

Hyponatremia

Obstructive sleep apnea

None of these

We ask because some conditions can determine which treatment types are right for you.

Do you take any medications to manage your high blood pressure?(Required)

Yes

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Please list the medication(s) you are taking to manage your high blood pressure.(Required)

Include exact names of any medicines (e.g. Norvasc, Lisinopril, Losartan)

What specific cancer have you been diagnosed with?(Required)

Have you undergone chemotherapy or surgical treatment, with the exception of melanoma skin cancer, in the last 6 months?(Required)

Yes

Other than surgery to remove melanoma from the skin, chemotherapy or surgical treatments for most cancers can affect the types of treatments that would be right for you.

Are you planning to undergo chemotherapy or surgical treatment in the future (other than surgery to remove melanoma from the skin)?(Required)

Yes

What kind of glaucoma have you been diagnosed with?(Required)

Narrow/closed angle glaucoma

Open angle glaucoma

I'm not sure

Have you received laser treatment for glaucoma?(Required)

Yes

Have you been diagnosed with any of the following liver conditions?(Required)

Fatty liver

Cirrhosis

Hepatitis

Something else

What liver conditions have you been diagnosed with?(Required)

What type of fatty liver disease do you have?(Required)

Alcoholic fatty liver disease

Non-alcoholic fatty liver disease

Have you had a heart attack in the last 6 months, or ongoing chest pain?(Required)

Yes

Are there any other medical conditions you haven't shared with us already?(Required)

Yes

Be sure to include any medical conditions that you treat with medications.

Please list any other medical conditions.(Required)

Have you or a family member ever been diagnosed with any of the following conditions?(Required)

Medullary thyroid carcinoma

Multiple endocrine neoplasia type-2

Pancreatitis

Gastroparesis (delayed stomach emptying)?

None of these

Do you have a personal history of pancreatitis?(Required)

Yes

Do you have a personal history of gastroparesis (delayed stomach emptying)?(Required)

Yes

Have you had any surgeries or medical procedures?(Required)

Yes

We ask this so your provider can have a complete understanding of your medical history so they can decide what is the best treatment for you.

Have you had any of the following weight loss surgeries or procedures?(Required)

Gastric bypass (Roux-en-Y)

Duodenal switch

Lap band

Gastric sleeve

None of these

Please tell us the dates and reasons for any surgeries or medical procedures.

Hidden

Please tell us the dates and reasons for any surgeries or medical procedures.(Required)

Do you currently take any medications or supplements?(Required)

Yes

Are you taking any of the following heart or blood pressure medications?(Required)

Atenolol (Tenormin)

Carvedilol (Coreg)

Hydrochlorothiazide (Hydrodiuril, Microzide)

Lisinopril (Prinivil, Zestril)

Losartan (Cozaar)

Metoprolol (Lopressor, Toprol XL)

Propranolol

None of these

What dose of hydrochlorothiazide (HCTZ) are you taking?(Required)

Less than 25mg daily

25mg or more daily

Do any of the medications you are taking contain hydrochlorothiazide (HCTZ) or chlorthalidone?(Required)

Yes, one or more contain hydrochlorothiazide (HCTZ)

Yes, one or more contain chlorthalidone

You're looking for chlorthalidone, hydrochlorothiazide, or HCTZ on your prescription label.

What total dose of hydrochlorothiazide (HCTZ) are you taking?(Required)

Less than 25mg daily

25mg or more daily

Are you taking any of the following medications?(Required)

Bupropion (Wellbutrin, Aplenzin)

Hydroxyzine

Insulin (any type)

Insulin secretagogue (sulfonylurea, glipizide, glyburide, glimepiride)

Lamotrigine (Lamictal)

Metformin (Glucophage, Riomet, Glumetza, Fortamet)

Naltrexone (Vivitrol, Revia)

Topiramate (Trokendi, Qudexy, Topamax)

Tamoxifen (Nolvadex, Soltamox)

Trintellix (Vortioxetine)

Spironolactone (Aldactone)

None of these

Does your spironolactone also contain hydrochlorothiazide (HCTZ)?(Required)

Yes

You're looking for hydrochlorothiazide or HCTZ on your prescription label.

What dose of hydrochlorothiazide (HCTZ) are you taking?(Required)

Less than 25mg daily

25mg or more daily

Please list any other current medicines, vitamins you take regularly that you haven't already told us about.

Include exact names of any medicines (e.g. Lipitor, Zyrtec, Ibuprofen)

Please list any other supplements you take regularly that you haven't already told us about.

Include exact names of any medicines (e.g. Lipitor, Zyrtec, Ibuprofen)

Hidden

Please list any other current medicines, vitamins, or dietary supplements you take regularly that you haven't already told us about.(Required)

Include exact names of any medicines (e.g. Lipitor, Zyrtec, Ibuprofen)

Do you have any allergies?(Required)

Yes

Include any allergies to food, dyes, prescriptions or over the counter medicines (e.g. antibiotics, allergy medications, sulfa drugs), herbs, vitamins, suppplements or anything else.

Hidden

Please list what you are allergic to and the reaction that each allergy causes.

Please list what you are allergic to and the reaction that each allergy causes.(Required)

How often do you consume 4 or more alcoholic drinks in one occasion?(Required)

Never

A few times a year

Once a month

Once a week

Daily or almost daily

Sometimes alcohol can impact the effectiveness of certain medications and it's important for your provider to know to give you the best guidance.

On a weekly basis, how many alcoholic drinks do you typically consume?(Required)

1 - 7

8 - 25

Over 25

Your response indicates potentially unhealthy alcohol use. Our recommendation is to try to cut back on alcohol use to a healthier level. Drinking alcohol while taking weight loss medication(s) is not advised because alcohol can worsen health. Alcohol can also increase the side effects of some medications, such as drowsiness, dizziness and coordination problems. It is recommended to avoid drinking alcohol while taking your medication, especially if you will be driving, operating dangerous machinery, or participating in dangerous activities. We encourage you to consult a licensed professional to help you cut back on alcohol use to a healthier level. You can find a licensed professional, support group, or treatment center in your area at [Psychology Today](https://www.psychologytoday.com).(Required)

Continue

Have you taken any of the following recreational drugs in the past 6 months?(Required)

Cocaine

Opiates/Opiods

Methamphetamine (Crystal Meth)

Cannabis

None of these

Have you taken any opiates/opioids, such as heroin or prescription opioid pain medications in the past 6 months?(Required)

Yes

Examples include, but are not limited to: morphine (MS Contin), hydrocodone (Vicodin), oxycodone (Oxycontin), hydromorphone (Percocet), codeine, tramadol; cough, cold, or diarrhea medicines that contain opioids; or opioid-dependence treatments, including buprenorphine or methadone.

Have you taken any opiates/opioids, such as heroin or prescription opioid pain medications in the last 14 days?(Required)

Yes

Naltrexone works by blocking the effects of opioids. It does this by blocking the areas of the brain where opioids attach, called opioid receptors. If you’re taking opioids when you start naltrexone, opioid withdrawal symptoms can occur. Common opioid withdrawal symptoms include nausea and vomiting, irritability, and sweating. You may also experience a runny nose, anxiety, and muscle aches. If you are starting naltrexone, stop taking opioids at least 7 to 14 days beforehand to avoid withdrawal.(Required)

I understand, continue

It is recommended to avoid using cannabis while taking your medication, especially if you will be driving, operating dangerous machinery, or participating in dangerous activities.(Required)

I understand, continue

Using cannabis products while taking certain medications, such as topiramate, is not advised because cannabis can worsen central nervous system depression. Combining cannabis and medications like topiramate may cause side effects of lower heart rate, lower breathing rate, confusion, irritability or cool, clammy skin.

Are you currently using any nicotine replacement products such as nicotine vapes or smoking cessation products?(Required)

Yes

We ask this to make sure there are no interactions with potential treatments.

Using nicotine replacement products while taking bupropion may cause episodes of elevated blood pressure without prior hypertension. Please inform your primary care provider so that monitoring of blood pressure can be done.(Required)

I understand, continue

When was the last time you or a healthcare provider checked your blood pressure?(Required)

Within the last 18 months

More than 18 months ago

We will need you to take your blood pressure at a local pharmacy, grocery store, or with a healthcare provider.(Required)

Got it, I will get a new blood pressure measurement and notify Regenics of the results as soon as I can.

Hidden

What was your last blood pressure reading?

Less than 90/less than 50

Less than 90/50-80

Less than 90/81-89

Less than 90/100 or higher

90-139/less than 50

90-139/50-80

90-139/81-99

90-139/100 or higher

140-169/less than 50

140-169/50-80

140-169/81-99

140-169/100 or higher

170 or higher/less than 50

170 or higher/50-80

170 or higher/81-99

170 or higher/100 or higher

I don't remember

What was your last blood pressure reading?(Required)

Less than 90 or higher than 140/Less than 50 or higher than 100

90-140/50-100

I don't remember

Since you don’t remember your exact blood pressure numbers, did your healthcare provider indicate any of the following about your blood pressure at your last visit?(Required)

My provider definitely checked my blood pressure and told me that it was normal.

My provider expressed concern about my blood pressure.

I don’t remember discussing my blood pressure with my provider.

In the last 3 months have you experienced any of the following? Fainting, almost fainting, severe headaches, blurry or double vision, recurrent nosebleeds.(Required)

Yes

We will need you to take your blood pressure at a local pharmacy, grocery store, or with a healthcare provider.(Required)

Got it, I will get a new blood pressure measurement and notify Regenics of the results as soon as I can.

We will need you to take your blood pressure at a local pharmacy, grocery store, or with a healthcare provider.(Required)

Got it, I will get a new blood pressure measurement and notify Regenics of the results as soon as I can.

In the last year, have you had a blood test?(Required)

Yes

Your answer will not affect your treatment eligibility.

Do you have easy access to your test results?(Required)

Yes

Test results are helpful for providers when determining treatment, but not a requirement.

Do your blood test results include your Creatinine level?(Required)

Yes

Unsure

Most routine blood work ordered by a provider includes a Creatinine level. This test could have been done at a recent physical, during a visit with a primary care provider or by a specialist where blood work was requested. These levels help determine which treatment dosage is right for you.

What was your latest Creatinine level?(Required)

Below 0.57 mg/dL

0.57 - 1.00 mg/dL

Above 1.00 mg/dL

I can’t find my creatinine level

You’re looking for “Creatinine.”

Now please tell your provider your exact Creatinine level shown in your lab report(Required)

Your answer should be reported in mg/dL.

Hidden

Please enter the exact date of your blood test, as written on your lab report.

Please enter the exact date of your blood test, as written on your lab report.(Required)

Month

Day

Year

Are you currently or have you ever taken a GLP-1 medication?(Required)

I am currently taking a GLP-1 medication

I've taken a GLP-1 medication in the past but I'm not currently

I have never taken a GLP-1 medication

Which GLP-1 medication(s) have you taken previously?(Required)

Liraglutide (Victoza, Saxenda)

Tirzepatide (Mounjaro, Zepbound or compounded)

Semaglutide (Ozempic, Wegovy or compounded)

Other GLP-1 medication

What other GLP-1 medication have you taken previously?(Required)

Which GLP-1 medication are you currently taking?(Required)

Liraglutide (Victoza, Saxenda)

Tirzepatide (Mounjaro, Zepbound or compounded)

Semaglutide (Ozempic, Wegovy or compounded)

Other GLP-1 medication

What other GLP-1 medication are you taking?(Required)

How long ago Liraglutide (Victoza, Saxenda) are you taking?(Required)

Currently taking

In the last month

Within the last 3-6 months

Within the last year

Over a year

What dose of Liraglutide (Victoza, Saxenda) are you taking?(Required)

Tell us your current dose in milligrams (mg) per week.

If you're prescribed a GLP-1 medication through Regenics, do you agree to stop taking your current liraglutide (Victoza, Saxenda) medication?(Required)

Yes, if prescribed, I agree to stop taking the liraglutide medication I was previously prescribed and will inform the healthcare provider who prescribed me this medication prior to doing so.

No, I prefer to continue my current liraglutide medication outside of the Regenics platform

How long ago Tirzepatide (Mounjaro, Zepbound or compounded) are you taking?(Required)

Currently taking

In the last month

Within the last 3-6 months

Within the last year

Over a year

Hidden

What dose of tirzepatide (Mounjaro, Zepbound, or compounded) are you taking?

2.5 mg

5 mg

7.5 mg

10 mg

12.5 mg

15 mg

Tell us your current dose in milligrams (mg) per week.

Hidden

What dose of Tirzepatide (Mounjaro, Zepbound or compounded) are you taking?

Tell us your current dose in milligrams (mg) per week.

If you're prescribed a GLP-1 medication through Regenics, do you agree to stop taking your current tirzepatide (Mounjaro, Zepbound, or compounded) medication?(Required)

Yes, if prescribed, I agree to stop taking the tirzepatide medication I was previously prescribed and will inform the healthcare provider who prescribed me this medication prior to doing so.

No, I prefer to continue my current tirzepatide medication outside of the Regenics platform

How long ago Semaglutide (Ozempic, Wegovy or compounded) are you taking?(Required)

Currently taking

In the last month

Within the last 3-6 months

Within the last year

Over a year

Hidden

What dose of Semaglutide (Ozempic, Wegovy or compounded) are you taking?

Tell us your current dose in milligrams (mg) per week.

Hidden

What dose of semaglutide (Ozempic, Wegovy, or compounded) are you taking?

0.25 mg

0.5 mg

1 mg

1.7 mg

2.0 mg

2.4 mg

Tell us your current dose in milligrams (mg) per week.

If you're prescribed a GLP-1 medication through Regenics, do you agree to stop taking your current semaglutide (Ozempic, Wegovy, or compounded) medication?(Required)

Yes, I agree to stop taking my current semaglutide medication & will inform my doctor who prescribed me this before doing so

No, I prefer to continue my current semaglutide medication outside of the Regenics platform

If you're prescribed a GLP-1 medication through Regenics, do you agree to stop taking your current GLP-1 medication?(Required)

Yes, I agree to stop taking my current GLP-1 medication & will inform my doctor who prescribed me this before doing so

No, I prefer to continue my current GLP-1 medication outside of the Regenics platform

Do you tend to get side effects from new medication?(Required)

Always

Sometimes

Never

I'm not sure

We ask so a provider can personalize your starting dose to help your body adjust and minimize side effects.

How do you feel about potentially experiencing nausea and upset stomach?(Required)

I want to minimize these side effects

I don't mind them if it means I can lose weight faster

I'm not sure

These side effects are common with weight loss medications. They're usually temporary and can often be managed with over-the-counter remedies

Do you want to continue with Tirzepatide or do you want to try something else?(Required)

Yes, Continue

No, I want to try something else

What dose of tirzepatide (Mounjaro, Zepbound, or compounded) are you taking?(Required)

2.5 mg

3.5 mg

5 mg

7.5 mg

10 mg

12.5 mg

Do you want to stay with your current dose?(Required)

Stay with your current dose

Increase Dose

Decrease Dose

Do you want to continue with semaglutide or do you want to try something else?(Required)

Yes, Continue

No, I want to try something else

What dose of semaglutide (Ozempic, Wegovy, or compounded) are you taking?(Required)

0.25 mg

0.5 mg

0.75 mg

1 mg

1.25 mg

1.50 mg

1.75 mg

2 mg

2.25 mg

2.5 mg

Do you want to stay with your current dose?(Required)

Stay with your current dose

Increase Dose

Decrease Dose

Hidden

According to your answer, you might qualify for:

Tirzepatide

Semaglutide

According to your answer, you might qualify for:

Would you like a boost with your weight loss?

Bio Boost

Bio Boost Plus

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Discover weight loss plans tailored to your needs. We take the time to learn about you, your habits, and your health history to ensure you have an attainable plan.

This intake pertains to the patient. If you are assisting someone else, please answer the questions with the patient's information and history.

Losing weight has never been so easy – and it doesn’t require restrictive diets. To create a custom plan for you, let’s start by building your weight loss profile.

According to your answer, you might qualify for:

Would you like a boost with your weight loss?

Losing weight has never been so easy – and it doesn’t require restrictive diets.

To create a custom plan for you, let’s start by building your weight loss profile.