• Peptide Therapy Questionnaire

    Please fill out all required fields to help us understand your health needs.
  • Date of Birth*
     / /
  • Format: (000) 000-0000.

  • Your Wellness Priorities

  • Which areas are you most interested in supporting? Select all that apply.*

  • Tissue Healing & Recovery

  • Which areas are you looking to support? Select all that apply.*
  • How long has this been a concern?*
  • Have you had imaging, surgery, or physical therapy for this?*

  • Metabolism & Body Composition

  • What is your primary focus?*
  • How would you describe your current activity level?*
  • Are you currently taking a GLP-1 or other weight loss medication?*

  • Anti-Aging & Cellular Health

  • Which of these matter most to you?*
  • How would you rate your sleep quality?*
  • Are you currently receiving aesthetic treatments (micro needling, facials, lasers)?*

  • Cognitive Function

  • Which of these matter most to you?*
  • How would you rate your daytime energy?*

  • Peptide Therapy Questionnaire

  • Have you used peptides before or are you currently using any now?*
  • Do you have an active cancer diagnosis or a personal history of cancer?*
  • Have you been told you have diabetes, prediabetes, or elevated blood sugar?*
  • Have you ever been diagnosed with diabetic retinopathy?*
  • Have you experienced carpal tunnel, joint swelling, or significant fluid retention?*
  • Do you have a known pituitary disorder, or have you previously been treated with growth hormone?*
  • Do you have a known sensitivity or allergy to copper?*
  • Do you have high blood pressure that is not well controlled?*
  • Are you pregnant, breastfeeding, or trying to conceive?*
  • Are you comfortable with self-administered subcutaneous injections?*
  • Is there anything else you would like your provider to know?*
  • Should be Empty: