enhancepsych.com - Peptide Intake Form

Patient Information
Patient Name*

First NameMiddle NameLast Name
Occupation*
Date of Birth*

MonthDayYear
Date
Height (feet/inches)
Weight *
Address*

Street Address

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CityState / Province

Postal / Zip CodeCountry
Cell Phone*
Format: (000) 000-0000.
Patient E-Mail*
How did you hear about Enhance Peptides & Longevity?*
Program Information
YesNo
If yes
Body composition – lose weight/fatBody composition – gain muscleMedically healthier – lower lipid levelsMedically healthier – lower blood sugarMental health optimization – more energyMental health optimization – brighter moodMental health optimization – more focusMental health optimization – less anxietyInjury healing & recovery – faster/betterAesthetics – better skin and hairLongevity – live longer & reverse agingOther
Semaglutide (Ozempic/Wegovy)Tirzepatide (Zepbound/mounjaro)RetatrutideBPC 157SelankOther:
Present Health
Please describe your present health concerns and their duration.
How long have you had the chronic conditions about which you are consulting us?
How have your health problems progressed since they began?
Please indicate the overall intensity of your symptoms.
Do you take any nonprescription drugs, vitamins and/or any other supplements? Please list them.
Do you currently take medication and/or receive medical treatment for your health condition(s)? If so, include all medications, treatments, and dosages.
Do you have any past medical history or problems (i.e.. illness, trauma, emotional stress, addictions, drug abuse, or anything else that will help us clearly understand your health condition)?
Miscellaneous
Do you have any allergies? If yes, please list them. *
Have you had any surgeries? If so, please specify.
How would you rate your usual energy level?
DepressionAnxietyChronic PainInflammationWorryLack of memoryLight-HeadednessLack of energyInsomniaHigh Stress levelsMenopause
Consent for Peptide Therapy

I voluntarily consent to peptide therapy, understanding its goals include improved vitality, recovery, and body composition. I understand risks may include fatigue, water retention, headaches, or hormonal changes. I agree to periodic monitoring including bloodwork. I understand results are not guaranteed.
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Patient Information

Program Information

Present Health

Miscellaneous