WELLHAUS PEPTIDE THERAPY DISCOVERY QUESTIONNAIRE
Client Information and Medical History for Peptide Therapy Consultation.
Client Name
*
First Name
Last Name
Client Email
*
example@example.com
Client Phone
*
Please enter a valid phone number.
Chief Concerns & Goals - What brings you to Wellhaus Peptide Therapy? (check all that apply)
Low Energy / Fatigue
Slow Metabolism / Weight Management
Muscle Tone & Performance
Recovery / Inflammation
Sleep Support
Hormonal Balance
Cognitive Focus / Brain Fog
Longevity / Anti-Aging
Immune Support
Skin / Hair Health
Libido / Sexual Wellness
Stress/Mood/Anxiety
Other
What else interests you about peptides.
Medical History - Please check all that apply (past or present)
Heart Disease / High Blood Pressure
Diabetes / Insulin Resistance
Thyroid Disorder
Liver or Kidney Disease
Autoimmune Condition
Cancer (current or past)
Seizures / Neurological Disorder
Hormone Therapy (current or past)
None of the Above
Please describe any relevant medical history
List all current prescriptions, over-the-counter medications, and supplements
Allergies
No Known Allergies
Medication Allergies
Food / Environmental Allergies
If medication or food/environmental allergies, please specify
Lifestyle - Sleep, Exercise, Hydration, Alcohol, Caffeine, Tobacco/Vaping details
Peptide Experience - Have you used peptides before?
*
Yes
No
If yes, which ones and when?
Any side effects or reactions?
Recent Labs - Have you had bloodwork within the past 6 months?
*
Yes
No
Would you like Wellhaus to review or order labs?
Yes
No
Contraindication Review - Do any of these apply to you?
Active or recent cancer
Severe liver or kidney disease
Uncontrolled diabetes
Pregnancy or breastfeeding
If yes, please explain
Submit Questionnaire
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