Weight Loss Form

Are you 18 years or older?* This field is required.You must be 18 years or older to receive treatment.

Terms and Conditions* This field is required.By clicking ‘I accept’, you agree that ZyNori may use your responses to personalize your experience and other purposes as described in our Privacy Policy. Responses prior to account creation will not be used as part of your medical assessment.

State* This field is required.This state is where your medication will be shipped to, if prescribed. If you do not see your state, we do not currently provide treatment in your area. Check back soon as we're continually expanding our coverage area.

What was your gender assigned at birth?* This field is required.Please select one

Female

Male

Nice! Looks like you're good to go on our end.

Let's continue with some questions about you and your lifestyle.

Your goal to lose weight is closer than you think - and it doesn't involve restrictive diets.

To find a custom plan for you, we'll need to build your Weight Loss Profile first.

Ready?

How many different weight loss programs have you tried in the past?* This field is required.Please select one

None, this is my first time trying

1–5

6–10

More than I can remember

What steps have you previously taken to lose weight?* This field is required.Please select one

l followed a diet program with a medical provider or dietician

l used a weight loss medication

Other

Do you have any family members who struggle with their weight?* This field is required.Please select one

Yes

Not sure

While it's not fate, family history
can explain why it's harder for
some people to lose weight.

This is likely because we inherit
genes that influence things like
our appetite and how quickly we
burn calories.

How would you describe the level of stress you experience in your daily life?* This field is required.Please select one

I rarely feel stressed

l feel stressed a few times a week

l feel stressed all the time

On average, how much sleep do you get a night?* This field is required.Please select one

More than 9 hours

7 to 9 hours

Less than 7 hours

It varies/I have trouble sleeping

Getting enough sleep is key to
losing weight.

A study over 16 years revealed
that sleeping less than 7 hours a
night can lead to a 15% increased
risk of weight gain.

Where do you hold most of your weight?* This field is required.Please select one

Around my stomach or waist

Hips and thighs

All over

Cortisol and insulin are two
hormones that influence how and
where we retain weight.

Now let's learn about your eating
habits and goals.

What time of day do you have food cravings?* This field is required.Please select one

Before bed

Afternoon

In the middle of the night

l don't have cravings

Which eating habit sounds most like you?* This field is required.Select all that apply

l'm usually multitasking when l eat

I snack between meals

I tend to snack when I'm stressed

I turn to food for comfort

l often reward myself with food

I eat out frequently (more than twice weekly)

l center my social life around dining out

I eat meals at irregular times

I eat until I'm overly full

I have excessive hunger

I tend to overeat / I eat large portion sizes

I eat pretty clean (I limit my intake of processed foods)

I tend to eat on the run

Crash diets may lead to quick weight loss, but they often cause rebound weight gain and disrupt your health.

Sustainable lifestyle changes—like balanced eating and movement that fits your routine—lead to long-term results.

What is your preferred diet?* This field is required.Please select one

Vegan (no animal products)

Vegetarian (some animal products)

Intermittent Fasting

Low-Carb

Low-Fat

High-Protein

Paleo

Keto

Balanced

No preference

Please indicate any dietary restrictions:* This field is required.

Current Daily Calorie Intake* This field is required.Please select one

500 - 1,000

1,000 - 1,500

1,500 - 2,000

Above 2,000

I don't track my calories

Tell us about your lifestyle* This field is required.Please select one

Sedentary (mostly sitting)

Active (standing most of the day)

Very Active (walking most of the day)

What type of exercise do you do?* This field is required.Please select one

Aerobic

Weight-Bearing

Stretching

Balance

I don't exercise at all

How frequently do you exercise?* This field is required.Please select one

Occasionally (1 x per week)

Sometimes (2-3 x per week)

Often (more than 3 x per week)

Never

What is your exercise intensity?* This field is required.Please select one

Low (walking, casual biking)

Moderate (light jogging, dancing)

High/Extreme (intense cardio, strength training)

None (I don't exercise)

What is the exercise duration per session?* This field is required.Please select one

Varies 30 min or less

30-45 min

45-60 min

Over 60 min

None

Weight loss surgery helps reduce overall body weight by changing how your digestive system works. It’s used for medical reasons and supports long-term weight loss.

Cosmetic fat reduction targets small areas of fat for shaping the body. It’s not meant for weight loss or treating obesity.

Have you had any weight reduction surgeries or procedures?* This field is required.Please select one

Yes

Please indicate the type of weight loss surgery or procedure you've had:* This field is required.

Bariatric

Liposuction

Gastric bypass / band

I've had a procedure, but I'm not sure which one

None

Other

Other type of weight loss surgery

What would reaching your goal weight mean for you?* This field is required.Select all that apply.

Having more energy

Feeling more confident

Improving overall health

Feeling better in my body

Feeling good in clothes

A healthy weight loss goal is 1–2 pounds per week. Losing too fast can be unsafe and lead to rebound weight gain, while losing too slowly can feel discouraging. Steady progress is key to lasting results.

Current Weight and Height* This field is required.

Is your current weight the most you have ever weighed?* This field is required.Please select one

Yes

I don't know

What is the most you have ever weighed?* This field is required.Please enter your highest weight in pounds (lbs). This information will help a provider determine the best treatment for you.

Enter weight in pounds (lbs)

What is your goal weight?* This field is required.Please enter your desired weight in pounds (lbs).

Goal Weight (lbs)

Have you ever experienced any of these symptoms?* This field is required.This helps your provider better understand your current health so they can recommend the best treatment for you.

Causing yourself to vomit in order to lose weight

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

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

No, I have not experienced any of these

Have you been diagnosed with a mental health condition?* This field is required.We ask this so your provider can have a complete understanding of your medical history. Some weight loss medications may contain antidepressants and some treatments for mental health may cause weight gain. .

Yes

Have you been diagnosed with any of the following conditions?* This field is required.Select all that apply

IBS (Irritable Bowel Syndrome)

Celiac

Chronic constipation

Heartburn

GERD or acid reflux

Diverticulitis

Crohn's disease

Ulcerative Colitis

Fatigue or low energy levels

No, none of these

Have you ever been diagnosed with any of the following conditions?* This field is required.We ask because some conditions can determine which treatment types are right for you.

Medullary thyroid cancer

Multiple endocrine neoplasia type-2

Pancreatitis

Gastroparesis (delayed stomach emptying)

Diabetes type 2

Uncontrolled Hypertension (high blood pressure)

Depression

Seizures

Substance Abuse

Low Testosterone or DHEA

Recreational Drugs

None of These

Are you currently taking or have you ever taken the following medications for weight loss?* This field is required..

GLP-1 medication (Semaglutide, Tirzepatide, Liraglutide)

Phentermine

Bupropion/Naltrexone

Orlistat

Topiramate

Other

Do you drink alcohol?* This field is required.Please select one

Yes

How often do you drink alcohol?* This field is required.Please select one

Rarely (less than once/week)

Moderate (1–2 times/week)

Frequent (3+ times/week)

Do you use caffeine?* This field is required.Please select one

Yes

How often do you use caffeine?* This field is required.Please select one

Rarely (less than once/week)

Moderate (1–2 times/week)

Frequent (3+ times/week)

What's the hardest thing about losing weight for you?* This field is required.Select your top three.

Controlling hunger or cravings

Staying motivated

Finding time to exercise

Staying on top of my diet

Cost of weight loss programs

Medication side effects

Medical conditions that affect weight loss

Other

Have you ever stopped a weight loss program before reaching your goal? If so, why?* This field is required.Select all that apply

l wasn't seeing results fast enough

l couldn't stick with it

lt became too expensive

l experienced side effects

Life got in the way (stress, travel, family obligations)

Other

No, I'm usually consistent

Preferred treatment option(s):* This field is required.Your weight loss plan will be a shared decision between you and your provider—your goals, preferences, and lifestyle are central to choosing the right treatment.

Bupropion/Naltrexone (starts at $95)

Semaglutide/Naltrexone/Cyanocobalamin Sublingual (starts at $150)

Liraglutide (starts at $299)

Add on: Lipotropic (starts at $30)

Add on: Sermorelin (starts at $100)

Add on: DHEA (starts at $15)

Zepbound (brand name, $1,150)

Aside from losing weight, is there another area of your health you'd like to improve?* This field is required.This helps us get a full picture of your health goals and find the right treatment options for you.

Better sex

Hair regrowth

Supplement support

Hormone balance

Anti-Aging

Lab testing

None

Is there anything else you would like your provider to know?* This field is required.

Address* This field is required.Please provide your mailing street address.

City* This field is required.Please enter your city

Zipcode* This field is required.Please enter your zip code