PEPTIDES FORM Please complete our online intake form below. This allows our doctor to review your file and approve you for any prescription deemed safe and appropriate for your weight loss and health needs. Your peptides will only be dispatched after the review. First Name(Required) Last Name(Required) Gender(Required)Please selectFemaleMaleDate of Birth(Required) DD slash MM slash YYYY Email(Required) Phone No(Required) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Name(Required) Emergency Contact Number(Required) Emergency Contact Relationship(Required) Primary Doctor's Name Primary Doctor's Contact No What is your weight? (Kg) What is your height? (cm) Do you have a personal history with any of the following? Breast Cancer Uterine Cancer Ovarian Cancer Prostate Cancer Thromboembolic Event (Blood Clot) Thromboembolic Disorder Coronary Heart Disease Myocardial Infarction (Heart Attack) Please list any other medical conditions you've been diagnosed with. Are you under a doctor's care at the present time? Yes No What are the goals you hope to achieve with peptides? Surgeries & Other Hospitalisations1. Reason / Diagnosis Hospital Year 2. Reason / Diagnosis Hospital Year 3. Reason / Diagnosis Hospital Year Allergies to Medication Please list any medications you have known allergies to: 1. Medication Name Purpose Reaction 2. Medication Name Purpose Reaction 3. Medication Name Purpose Reaction List any prescribed medications, over-the-counter drugs, dietary supplements (include vitamins, inhalers, etc.) 1. Medication Name Dose Frequency 2. Medication Name Dose Frequency 3. Medication Name Dose Frequency 4. Medication Name Dose Frequency 5. Medication Name Dose Frequency Marital Status Employment Status How many meals do you consume a day? How would you describe your diet? How often do you exercise? How many hours do you sleep a night? Do you take sleeping aids? Yes No What Types of Caffeine Do You Drink? Coffee Tea Soda None How Many Cups/Cans Per Day?Do You Drink Alcohol? Yes No How Often? Do You Smoke? Yes No How Many Cigarettes Per Day?For How Many Years?Did You smoke in the past? Yes No When did you stop? Are you currently sexually active? Yes No Are you in a committed, mutually monogamous relationship? Are you trying to get pregnant? Yes No If not, do you practice safe sex? Yes No If yes, list contraceptive / barrier method Please select all of the following that apply: Decline in your feeling of general well-being Difficulty concentrating Memory problems Physical exhaustion/Lacking vitality (General decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, having to force oneself to undertake activities) Low energy, often feeling tired and fatigued Increased need for sleep Sleep problems (Difficulty in falling and or staying asleep) Weight gain Difficulty losing weight Decrease in muscular strength (Feeling of physical weakness) Joint pains and/or muscle aches Depressed mood (Feeling down, sad, on the verge of tears, lack of drive/motivation) Anxiety (Feeling panicky) Nervousness (Inner tension, restlessness, feeling fidgety) Irritability (Feeling aggressive, easily upset by little things, moody) Mood swings Emotional Females OnlyHow would you describe your current menstrual status? Age at first menstrual period? Approximate date of your last menstrual period? Are your periods usually regular? How often do they usually occur? How many days does your period usually last? If you no longer having periods, at what age did you have your last period? If you no longer having periods, Was your menopause? Do you have a cervix? Yes No Do you have a uterus? Yes No Do you have both ovaries? Yes No History of abnormal results? When was your last mammogram? Please indicate method of birth control Have you been pregnant? Please select all that apply Hot flashes Night sweats Irregular periods Shorter cycles Longer cycles Lighter periods Heavier periods Spotting or bleeding between periods Painful periods Abnormal vaginal bleeding after menopause PMS (including but not limited to mood swings, bloating, cramping, breast tenderness, and/or headaches prior to period) Decrease in sexual interest/ desire/ libido (lacking pleasure in sex, lacking desire for sexual intercourse) Loss of sexual response (weaker or absent orgasm) Vaginal dryness Pain during intercourse More frequent urinary tract/bladder infections Incontinence Frequent urination Excessive urination Vaginal itching Abnormal vaginal discharge Increased vaginal infections Males OnlyWhen was your last PSA level tested? Any elevated results? If yes, when? When was your last prostate exam? Any abnormal findings, if yes what? Please select all that apply Frequent urination throughout the night Decreased force of urination Feeling of incomplete emptying of bladder after urination More frequent urinary tract/bladder infections Decrease in sexual interest / desire / libido (lacking pleasure in sex, lacking desire for sexual intercourse? Feeling that you have passed your peak sexually Decrease in ability and / or frequency to perform sexually Decrease in the number of morning erections Difficulty obtaining / maintaining an erection Loss of sexual response / ejaculation (weaker or absent orgasm) Consent(Required) Agreement to our terms and conditionsI have read and agree to the content of this consent documentNameThis field is for validation purposes and should be left unchanged.
