Patient Intake Form

Section 1 — Basic Info

Full Name *

Street Address *

City / State / ZIP *

Date of Birth *

Phone Number *

Email *

Gender

Height (in)

Weight (lbs)

Qualification Path

Section 2 — Verification & Medication Choice

Current Body Fat %

Email proof (DEXA, scale scan, app notes) to peptideprotocolsmd@gmail.com

Proof Details / Notes

Medication Type Options (check all that apply)

Section 3 — Goals & Health Screening

Primary Reasons for Treatment (check all that apply)

Recreational drug use? *

Existing Conditions (check all that apply)

Triglycerides ≥ 500? *

High blood pressure meds? *

Taking Warfarin? *

Section 4 — Medical History

Thyroid History (check all that apply)

Gallbladder disease? *

Tumors / Cancers? *

Pre-diabetic / Diabetic? *

Sleep Apnea / CPAP use? *

Other Medical Conditions (check all that apply)

Past Surgeries

Current Prescription Meds (Name, Dose, Frequency) *

OTC Meds / Vitamins / Supplements

Section 5 — Allergies, History & Vitals

Medication / Food / Injection Allergies? *

Other relevant medical history? *

Prior Peptide Therapy? *

Blood Pressure — Systolic

Diastolic

Last Menstrual Period (if applicable)

Peptides of Interest (check all that apply)

Current Symptoms & Desired Results

Duration of Concerns

Section 6 — Consents & Submission

Please read and check each consent below. All four are required.

Signature (Type Full Legal Name) *

Date

Referral Type

This report covers cholesterol, complete blood count, omega3/omega6 ratios, genetic mutations, food sensitivities, pollen allergies, gut health, heart health, liver function, pancreatic function, thyroid function, lung function, brain nerves and potential dementia, heavy metal toxicity, parasitic infection, bacterial infection including Lyme disease, viral infections and fungal overgrowths. This valuable information can help you take your overall wellness to the next level! Check the box if this is something that interests you.