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Patient
Medical Practitioner
Health Club Owner
Insurance Company
Contact Us
Privacy Policy
GLP-1
Have you used ReEnvision in the past?
Yes
No
Not Sure
To start, we’ll need an email address to contact you about your health assessment. (You’ll use this same email address to sign in in the future.)
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We’ll begin your health assessment in a moment. But first, a little housekeeping. 🧹
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I agree
I acknowledge that I have read, understood, and agree to the Telehealth Informed Consent and Notice of Privacy Practices
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I agree
To route you to a provider in your state, we need to know your location.
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I am currently in Virginia
I am in another State
I am in another State
What is your first name? (as written on your ID)?
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What is your last name?
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What is your date of birth?
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And what’s your address?
What’s your phone number? (This may be needed to get in touch with you about your consultation)
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What sex were you assigned at birth?
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Male
Female
Got it. And what is your gender identity? We ask everyone this question in order to provide you with the best care possible.
Male
Female
Nonbinary
Genderqueer
Transgender
I prefer not to say
Okay, let’s begin your health assessment.
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I’m Ready
Is this your first time doing a consultation for prescription weight loss medication with ReEnvision?
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Yes, this is my first time
No, I’ve done this before
First, are you already taking a GLP-1 prescription weight loss medication at this time, or have you been on one in the past? This includes (but is not limited to):
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No, I’ve never taken prescription weight loss medication
Semaglutide (Wegovy, Ozempic, Rybelsus)
Tirzepatide (Mounjaro, Zepbound)
Liraglutide (Victoza, Saxenda)
Exenatide (Byetta, Bydureon)
Dulaglutide (Trulicity)
Now let’s calculate your body mass index (BMI). First, how tall are you?
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What’s your weight?
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Next, please select any/all of the following conditions you’ve been diagnosed with.
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Diabetes Type 2
Heart Disease
High Triglycerides
Hyperlypidemia (high cholesterol)
Hypertension
Nonalcoholic fatty liver disease
Osteoarthritis
Polycystic ovary syndrome (PCOS)
Pre-Diabetes
Sleep Apnea
None of the above
Do you have a history of severe hypoglycemia (a drop in glucose levels) that has required treatment by a medical professional?
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Yes
No
Do you have a history of any eating disorders, such as anorexia or bulimia?
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Yes
No
Do you have any history of pancreatitis or gall bladder disorder?
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Yes
No
Have you had any of the following weight loss or digestive tract surgeries?
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None of these
Gastric bypass
Gastric sleeve
Lap band
Gastric balloon
Any other digestive tract surgeries
Any other digestive tract surgeries
Do you have a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2?
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Yes
No
Do you have a history of any of the following? If so, please select all that apply.
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None of these
Thyroid disease
Thyroid cancer
Hyperthyroidism
Hypothyroidism
Though rare, some reports have linked this medication with an increased risk of diabetic retinopathy, diabetes-related vision loss and other eye conditions, including blindness. Do you acknowledge these risks and agree to consult an ophthalmologist if necessary?
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Yes
No, I can’t
Do you have a history of depression or any other mental health condition?
Yes
No
Do you have a history of suicidal thoughts or behaviors?
Yes
No
Have you ever been diagnosed with or treated for any of the following?
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None of these
Heart arrhythmias
Atrial fibrillation (Afib)
Atrial flutter
Wolff-Parkinson-White (WPW)
Supra ventricular tachycardia (SVT)
Semaglutide can cause an increase in heart rate. Do you have tachycardia, or has your doctor ever informed you that you have an elevated resting heart rate (RHR)—a rate above 100 beats per minute?
Yes
No
Okay. Now, let’s collect your resting heart rate—the number of times your heart beats per minute when you’re at rest, typically measured after waking up but before getting out of bed. To measure your RHR, find a quiet place. Sit or lie down, and relax for a few minutes. With your index and middle fingers, locate your pulse on your wrist or neck. For 60 seconds, count the number of beats you feel.
Below 60
60-90
70-79
80-89
90-99
100 or above
Please confirm that you won’t exceed recommended alcohol limits while taking Semaglutide and that if you do, you’ll pause this treatment and contact your primary care doctor to discuss your safest path forward.
Yes, I confirm
No, I can’t promise that right now
Semaglutide increases pancreatitis risk and should not be taken if you are at risk for alcohol abuse. This means more than 4 drinks on any day or more than 14 drinks per week.Do you currently drink alcohol at this quantity?
Yes
No
Are you taking any other medications or herbal products for weight loss? Examples include:
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None of these
Insulin
Glimepiride (Amaryl)
Tolinase (Tolazamide)
Tolbutamide (Tol-Tab)
Glyburide (Micronase, Glynase, Glycron, DiaBeta)
Glipizide (Glucotrol)
Are you taking any of the following medications?
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None of these
Phentermine
Plenity
Metformin
Are you taking any of the following medications?
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None of these
Semaglutide (Wegovy, Ozempic, Rybelsus)
Tirzepatide (Mounjaro, Zepbound)
Liraglutide (Victoza, Saxenda)
Exenatide (Byetta, Bydureon)
Dulaglutide (Trulicity)
Prescription weight loss medications should not be attempted before you have tried to lose weight through lifestyle changes like diet and exercise.
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Understood
Can you confirm that you’ve actively tried to lose weight by modifying your diet and regularly exercising for at least 6 months straight? You can have done this independently or though a weight loss or fitness program.
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Yes, I have
No, I haven’t
Please list all medications you are taking.
Do you have any known drug allergies?
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No, I don’t have known drug allergies
Yes, I do have drug allergies
Yes, I do have drug allergies
Please upload a picture of the front of your insurance card.
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Drop a file here or click to upload
Choose File
Maximum file size: 15.36MB
Please upload a picture of the back of your insurance card.
*
Drop a file here or click to upload
Choose File
Maximum file size: 15.36MB
Got it. Based on your answers, you don’t need to have a video consult we will reach out with a time a date or you can call our offices at: (xxx)xxx-xxxx
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Understood
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