Step
1
of
111
0%
Hidden
Tirzepatide
5mg
7.5mg
10mg
Hidden
Semaglutide
5mg
7.5mg
10mg
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.
Is this treatment for you or someone else?
(Required)
Myself
Someone else
This intake pertains to the patient. If you are assisting someone else, please
answer the questions with the patient's information and history.
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)
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)
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
(Required)
Please enter a number greater than or equal to
100
.
What is your desired weight?
(Required)
Is your current weight the most you have ever weighed?
(Required)
Yes
No
Please include only your highest non-pregnant weight.
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: Also known as Zepbound or Mounjaro
Semaglutide: Also known as Wegovy or Ozempic
Orlistat: Also known as Xenical or Alli
Phentermine-topiramate: Also known as Qsymia
Naltrexone-bupropion: Also known as Contrave
Liraglutide: Also known as Saxenda
Phentermine
Metformin
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)
No
Yes, I am currently pregnant or trying to become pregnant
Are you currently breastfeeding?
(Required)
No
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
No
Have you purged or forced yourself to vomit in order to lose weight within the last 12 months?
(Required)
No
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)
No
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)
No
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)
No
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)
No
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)
No
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)
No
Yes
Hidden
Please list the medication(s) you are taking to manage your high blood pressure.
(Required)
Add
Remove
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)
No
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)
No
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)
No
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)
No
Yes
Are there any other medical conditions you haven't shared with us already?
(Required)
No
Yes
Be sure to include any medical conditions that you treat with medications.
Please list any other medical conditions.
(Required)
Add
Remove
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)
No
Yes
Do you have a personal history of gastroparesis (delayed stomach emptying)?
(Required)
No
Yes
Have you had any surgeries or medical procedures?
(Required)
No
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.
Add
Remove
Hidden
Please tell us the dates and reasons for any surgeries or medical procedures.
(Required)
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 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)
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
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.
What dose of Tirzepatide (Mounjaro, Zepbound or compounded) 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 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
What dose of Semaglutide (Ozempic, Wegovy or compounded) are you taking?
(Required)
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
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)
How long ago Liraglutide (Victoza, Saxenda) were you taking?
(Required)
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.
How long ago Tirzepatide (Mounjaro, Zepbound or compounded) were you taking?
(Required)
In the last month
Within the last 3-6 months
Within the last year
Over a year
What dose of Tirzepatide (Mounjaro, Zepbound or compounded) are you taking?
(Required)
Tell us your current dose in milligrams (mg) per week.
How long ago Semaglutide (Ozempic, Wegovy or compounded) were you taking?
(Required)
In the last month
Within the last 3-6 months
Within the last year
Over a year
What dose of Semaglutide (Ozempic, Wegovy or compounded) are you taking?
(Required)
Tell us your current dose in milligrams (mg) per week.
Do you currently take any medications or supplements?
(Required)
No
Yes
Are you taking any of the following heart or blood pressure medications?
(Required)
Atenolol
Carvedilol
Hydrochlorothiazide (HCTZ)
Lisinopril
Losartan
Metoprolol
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
No
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
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
None of these
Does your spironolactone also contain hydrochlorothiazide (HCTZ)?
(Required)
Yes
No
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.
Add
Remove
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.
Add
Remove
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)
No
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)
Add
Remove
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)
No
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)
No
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.
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)
No
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
No
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
No
Your answer will not affect your treatment eligibility.
Do you have easy access to your test results?
(Required)
Yes
No
Test results are helpful for providers when determining treatment, but not a requirement.
Do your blood test results include your Creatinine level?
(Required)
Yes
No
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.
Please enter the exact date of your blood test, as written on your lab report.
(Required)
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
According to your answer, you might qualify for:
Tirzepatide
Select
Semaglutide
Select
Would you like a boost with your weight loss?
Bio Boost
Bio Boost Plus
