• Peptide Therapy – Patient Medical Questionnaire

  • For completion prior to your appointment

  • Purpose: This questionnaire helps your clinician understand your health history, symptoms and goals to support safe care. Answer as accurately as you can. If you are unsure, leave blank and discuss during your consult.
  • Important: Completing this form does not mean a treatment will be prescribed. Some therapies discussed may be off-label or unapproved in Australia and require careful risk-benefit assessment, monitoring and informed consent.

  • 1) Patient details

  • Date of birth:*
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  • Format: 0000 000 000.
  • Medicare expiry date:*
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  • Format: 0000 000 000.
  • Format: 0000 000 000.

  • Measurements

  • 2) Your goals (tick all that apply, then rank your top 3)

  • Tick any goals that are relevant:*

  • Rank your top 3 goals (write the goal code - e.g. G1):

  • 3) Current symptoms (last 2–4 weeks)

  • Current symptoms (last 2-4 weeks) Please rate severity (0 = none, 10 = severe) and add comments if helpful.

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  • 4) Medical history (tick all that apply)

  • Please tick any current or past conditions and add brief details where relevant.
  • Medical History Conditions*
  • Medical History Conditions*

  • 5) Reproductive and hormonal health (complete the parts relevant to you)

  • If you can become pregnant:
  • If you have testes/prostate (if applicable):

  • 6) Medications, supplements and allergies

  • List all current medications (including prescriptions, over-the-counter medicines, herbal products and supplements).
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  • Do you take any of the following?*

  • 7) Lifestyle (tick and/or write)

  • These factors can change safety, effectiveness and monitoring needs.*
  • Exercise:*
  • Diet pattern:*
  • Are you currently being monitored by a prescriber and/or having regular tests (e.g., blood tests, liverfunction, blood pressure)?*

  • 8) Safety screening (please tick if you have any of the following now)

  • Your clinician may need further assessment before any therapy is considered.*

  • 8A) Product-specific safety questions

    Please answer the questions below that relate to any peptide you may be considering. If a peptide doesnot apply to you, tick N/A.
  • CJC-1295: Do you have a history of histamine sensitivity or histamine-related reactions (e.g., flushing,rash, hives, swelling, wheezing, anaphylaxis)?*
  • TB-500 / Thymosin Beta-4: Do you have any current or past history of cancer, suspected cancer, or other conditions associated with abnormal cell growth or angiogenesis?*
  • GHK-Cu: Do you have, or have a history of, a copper metabolism disorder (including Wilson’s disease),elevated copper levels, or a known allergy/sensitivity to copper or copper-containing products?*

  • 9) Previous peptide / hormone therapy (if any)

  • Rows

  • 10) Optional: therapies you are interested in discussing

  • This section is optional. Ticking a therapy does not mean it is suitable or will be prescribed. Your clinician will discuss evidence, risks, alternatives and monitoring.
  • A) Therapy areas (tick any you want to discuss)*
  • B) Specific products (tick if you want to discuss)*
  • 11) Consent to obtain and review pathology*
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  • 11A) Consent to SMS and email communication*
  • 11B) Consent to release health information to Pharmacy*

  • You may withdraw this consent at any time by notifying Peace Health Clinic via post or phone or email.

  • 12) Patient declaration

  • By signing this form ,I declare that the information I have provided is true and complete to the best of my knowledge. I understand that any therapy discussed requires individual assessment, and that I can ask questions and decline treatment at any time.

  • Date*
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