Intake Form

Welcome to PurePep Consulting
Welcome to PurePep Consulting.

We’re excited to support you on your journey toward better health, energy, recovery, and confidence.

This intake helps us understand you as a whole person so we can guide you safely and effectively.

Please answer honestly. All information is kept private and handled with care.
About You
Full Name *
Preferred Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date Of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Goals & Motivation
What inspired you to start this journey with PurePep?
What are your top 3 goals right now?
Examples: Fat loss, energy, confidence, recovery, longevity......
Your Daily Life & Habits
How would you describe your current nutrition style?
Examples: structured, flexible, inconsistent, tracking macros, intuitive, etc.
List any supplements you currently use.
Do you consume alcohol? If yes, how often?
Do you use tobacco or vape?
Average hours of sleep per night
How would you rate your sleep quality?

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3

4

5

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7

8

9

10

1 is Very Poor, 10 is Excellent
Describe your current exercise routine (if any)
Current stress level

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2

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4

5

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9

10

1 is Very Low, 10 is Very High
What are your primary sources of stress?
Health & Wellness Background
YesNo
Provider name (if yes)
Please list any medications, hormones, or therapies you are currently using.
Have you used peptides, testosterone therapy, or other hormone or performance-related therapies in the past?
Have you experienced any side effects or concerns with past programs?
Optional Uploads
Upload recent labs, body composition reports, or progress photos (optional)

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Safety & Support Information
Emergency Contact Name
Primary Care Provider Name
Known allergies or sensitivities
I understand that PurePep Consulting LLC provides education, guidance, and wellness consulting services only.

I acknowledge that PurePep Consulting LLC does not diagnose, treat, prescribe, or provide medical advice, and does not replace care from a licensed healthcare provider.

Any information discussed, shared, or reviewed is for educational purposes only and should be reviewed with my licensed healthcare provider before making any health-related decisions.

I understand that I am solely responsible for my health decisions and outcomes and agree to consult with my healthcare provider regarding medications, hormones, peptides, or therapies.

I agree to communicate honestly, follow safety recommendations, and notify my consultant of any adverse effects or concerns.
Signature*
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Welcome to PurePep Consulting

About You

Your Goals & Motivation

Your Daily Life & Habits

Health & Wellness Background

Optional Uploads

Safety & Support Information