IMHS Peptides & Performance Therapy Patient Intake

IMHS Peptides & Performance Therapy Patient Intake

Innovative Men’s Health | Bellevue, WA | (425) 455-1700 | innovativehealthsolutions.net — Please complete this intake so our clinical team can understand your symptoms, medical history, current medications, and performance or recovery goals. A licensed provider will review your information to determine whether peptide therapy may be appropriate. Submission does not guarantee treatment or a prescription. We’ll contact you about required labs, consultation, and next steps.
Patient Information
Full Legal Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Biological Sex
Age
Last 4 of National ID
Marital Status
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Occupation / Employer
Emergency Contact
Full Name

First NameMiddle NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral and Peptide-Therapy Goals
How did you hear about Innovative Men's Health?
Primary reasons for seeking peptide therapy

Other
Main goals for peptide therapy
Primary State of Residence
Current and Past Medical History
Medical Conditions
Please provide details about any conditions selected above, including diagnosis date, current status, treatments, and any relevant notes.
Allergies
Drug/Medication Allergies and Reactions
Other Allergies (Food, Latex, Environmental) and Reactions
Current Medications and Supplements
Current prescription medications
Vitamins, supplements, peptides, and over-the-counter products taken regularly
Prior Peptide / Hormone / Performance Use
Prior peptide, hormone, or performance-related therapies used
Details of prior use (what was used, dose, duration, when stopped, prescriber if applicable)
Peptide Interests and Goals
Which peptide categories are you interested in?
Please describe your specific goals or desired outcomes
Current Symptom and Goal Severity
Low energy / fatigue

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0 is None, 10 is Severe
Slow recovery from workouts or injury

0

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10

0 is None, 10 is Severe
Joint pain / stiffness

0

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10

0 is None, 10 is Severe
Difficulty building or maintaining muscle

0

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8

9

10

0 is None, 10 is Severe
Increased body fat

0

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8

9

10

0 is None, 10 is Severe
Poor sleep quality

0

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10

0 is None, 10 is Severe
Brain fog / concentration

0

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10

0 is None, 10 is Severe
Low libido / sexual function

0

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4

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8

9

10

0 is None, 10 is Severe
Mood / motivation issues

0

1

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8

9

10

0 is None, 10 is Severe
Skin aging / collagen concerns

0

1

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10

0 is None, 10 is Severe
How long have these concerns or goals been present?
Lifestyle and Body Metrics
Height (inches)
Current Weight (lb)
Goal Weight (lb)
Waist (inches)
Typical Blood Pressure (if known)
Exercise Days per Week
Exercise Types / Details
Average Sleep Hours per Night
Sleep Quality
Snore or stop breathing at night?
Approximate Alcoholic Drinks per Week
Tobacco / Nicotine / Vape Use
Cannabis / THC Use
Other Substances
Daily Stress Level
Typical Diet / Nutrition Notes
Family Medical History
Family medical conditions in relatives
Additional family history details
Recent Laboratory Results
Have you had recent laboratory results in the past 12 months?
Please provide the approximate date and any recalled lab values or details (for example: IGF-1, growth hormone, CBC, CMP, lipids, or other relevant results)
Other Providers and Pharmacy
Primary Care Physician Name
Primary Care Clinic and Phone
Other Specialists Seen Regularly
Acknowledgments and Consents
Information provided is true, complete, and accurate
Consent to telehealth evaluation, consultation, and treatment when appropriate
Acknowledgment of Notice of Privacy Practices and consent to use or disclosure of health information for treatment, payment, and healthcare operations
Agreement to baseline and ongoing laboratory testing
Understanding of potential peptide-therapy risks and side effects, including injection-site reactions, water retention, glucose changes, rare allergic reactions, and unknown long-term effects of some compounds
Agreement to recommended follow-up, monitoring, and communication
Understanding that services may be cash-pay/self-pay and insurance coverage is not guaranteed
Opportunity to ask questions and right to decline treatment
Agreement to provide government-issued photo identification for telehealth prescribing and medical records
Patient Signature / Attestation
Electronic Signature Attestation
Patient Full Legal Name / Electronic Signature

First NameMiddle NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient
gaClientId
gaSessionId
analyticsConsent
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IMHS Peptides & Performance Therapy Patient Intake

Patient Information

Emergency Contact

Referral and Peptide-Therapy Goals

Current and Past Medical History

Allergies

Current Medications and Supplements

Prior Peptide / Hormone / Performance Use

Peptide Interests and Goals

Current Symptom and Goal Severity

Lifestyle and Body Metrics

Family Medical History

Recent Laboratory Results

Other Providers and Pharmacy

Acknowledgments and Consents

Patient Signature / Attestation