Peptide Quiz
We will contact you regarding your answers.
Please answer the questions below to the best of your ability.
Name
First Name
Last Name
Medical History check the following that apply:
I have decreased libido
I have decreased ability to sleep
Elevated lipids
Mood Swings
Unexplained weight gain
Mental fogginess
Decreased muscle strength
Irritability
Low energy
Decreased Motivation
I have a muscle injury that will not heal.
My immune system has not been very good lately.
Please list any medications you are currently taking including vitamins and dietary supplements.
Please list any surgeries/ hospitalizations: (date and describe
Please list any drug allergies you may have.
My chronological age is
I feel this old
Please list any of these conditions if you have been diagnosed with them.
Please check the following that apply:
Cancer
Diabetes
Seizures
Arthritis
Thyroid problem
Asthma/COPD
Depression
Anxiety
Active Smoker
Recreational Drug Use
CAD
High BP
Stroke
Vascular Problems
Hormone Imbalance (PCOS)
Fertility Issues
What are your goals for wellness and peptide therapy?
Date
-
Month
-
Day
Year
Date
Signature
Submit
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