Peptide Therapy Questionnaire

Full Name

Current Age

Date of birth

Phone *

Email *

Please select your biological sex *

Female

Male

Health History

History of cancer (pituitary, breast, thyroid, or other hormone-sensitive)? *

Yes

Current or suspected pregnancy / breastfeeding? *

Yes

Known allergy or hypersensitivity to peptide medications? *

Yes

Active liver or kidney disease? *

Yes

History of thyroid disorder? *

Yes

History of diabetes or elevated blood sugars? *

Yes

History of sleep apnea? *

Yes

Currently taking GLP-1 weight loss therapy (Semaglutide, Tirzepatide, etc.)? *

Yes

Currently on hormone replacement therapy (pellets, creams, injections)? *

Option 1

Option 2

Option 3

Please list any other significant medical conditions:

Please list all current medications, supplements, or hormones:

Have you ever used peptide therapy before? *

Yes

If yes, which one(s) and what was your response?

Symptom & Wellness Check (Check all that apply) *

Low energy / fatigue

Poor sleep / difficulty staying asleep

Low muscle mass / slow recovery after exercise

Increased belly fat / sluggish metabolism

Brain fog / memory changes

Low mood or lack of motivation

Other

Goals for Peptide Therapy (Check all that apply) *

Improve sleep quality

Support lean muscle & recovery

Increase energy / vitality

Assist with metabolism & weight management

Support skin / hair / anti-aging

Other

Captcha

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