Peptides: Patient Eligibility & Health Assessment Questionnaire

Do you have any of the following medical conditions? (Select all that apply)

Do you have any of the following? (Select all that apply)

Are you currently on any of the following medical programmes? (Select all that apply)

Concurrent stimulant use Addiction recovery support Exercise recovery Not applicable

What is your height?

What is your weight?

Overall Wellness and Goals

PROMIS GH-1 – In general, how would you rate your overall physical health?

PROMIS GH-5 – In general, how would you rate your overall mental and emotional health?

Compared to 12 months ago, how would you describe your overall sense of health and vitality?

Please select your top 3 treatment goals. Your answers determine which health assessment sections you will be asked to complete.

AUDIT-C – How often do you have a drink containing alcohol?

AUDIT-C – On a typical drinking day, how many standard drinks do you consume?

AUDIT-C – How often do you have 6 or more standard drinks on a single occasion?

Clinical Disclosures

Are you currently taking any prescription medications, over-the-counter medications, or supplements?

Yes No

Please provide more information:

Have you previously received peptide therapy, hormone replacement therapy (HRT/TRT), or growth hormone treatment?

Yes No

Please provide more information:

Have you ever experienced an allergic reaction or adverse event from any peptide, supplement, or compounded medication?

Yes No Not sure

Please provide more information:

3.1 – RECOVERY, REPAIR, AND MUSCULOSKELETAL HEALTH ASSESSMENT

NRS – Rate your average musculoskeletal pain over the past 7 days

KOOS-12 – Do you experience joint stiffness upon waking? If so, how long does it persist?

None Less than 30 minutes 30–60 minutes More than 60 minutes

VISA Tendinopathy – Do you have a current or recurring history of tendinopathy, ligament tears, or soft-tissue injuries?

Yes – currently symptomatic Yes – recurring but currently resolved No

Do you notice a measurable worsening of joint pain, swelling, or stiffness after consuming specific foods or alcohol?

Yes – consistently Yes – sometimes No I have not tested this

LEFS – Do you feel significantly stronger or more mobile on one side of your body compared to the other?

Yes – left side dominant Yes – right side dominant No noticeable difference Unsure

How many musculoskeletal injuries have kept you from training or normal activity for more than 1 week in the past 24 months?

None 1–2 3–4 5 or more

DASH – Do you experience pain, weakness, or reduced function in your shoulder, arm, wrist, or hand during daily activities?

Yes – significantly limits me Yes – mildly limits me Occasionally No

How long does it typically take for muscle soreness (DOMS) to fully resolve after a hard training session?

Less than 24 hours 24–48 hours 48–72 hours More than 72 hours

Are you currently under the care of a physiotherapist, sports physician, or rehabilitation specialist?

Yes – actively attending Yes – but not currently attending No – but I have previously No

BPI – How much has pain interfered with your general activity, mood, or enjoyment of life over the past week?

3.2 – IMMUNITY, RESILIENCE, AND INFLAMMATION HEALTH ASSESSMENT

IFQ – How many times have you experienced a cold, flu, or respiratory infection in the past 12 months?

0–1 2–3 4–5 6 or more

Chalder Fatigue Scale – After a cold or flu, how long does it typically take for your energy levels to return fully to baseline?

Less than 3 days Approximately 1 week 2 weeks More than 2 weeks / not fully recovered

How many courses of antibiotics have you completed in the past 24 months?

0 1–2 3–4 5 or more

Do you notice frequent or persistent swelling of lymph nodes (neck, armpits, or groin) independent of an acute illness?

Yes – frequent Yes – occasional No

ARIA Classification – Do you have a current diagnosis or ongoing symptoms of any of the following? (Select all that apply)

Do you have a current or past diagnosis of any autoimmune or immune-mediated condition?

Yes – active / currently managed Yes – in remission Under investigation No

Do you consistently become unwell following periods of high psychological stress, international travel, or sleep deprivation?

Yes – reliably Yes – sometimes Rarely No

Chalder Fatigue Scale – Rate your overall physical fatigue level over the past month.

Have you had any recent blood tests showing elevated inflammatory markers (CRP, ESR, IL-6, ferritin)?

Yes – elevated result in past 12 months Yes – tested, results were normal No – not tested recently I don't know

Do you regularly experience any of the following digestive symptoms? (Select all that apply)

Bloating or abdominal distension Food intolerances (non-IgE) Irregular bowel movements (constipation or diarrhoea) Heartburn / GERD None of the above

3.3 – BIOLOGICAL AGEING AND AESTHETIC VITALITY HEALTH ASSESSMENT

Do you currently apply SPF 50+ broad-spectrum sunscreen to your face and neck on a daily basis?

Yes – every day Yes – when outdoors only Rarely No

Have you noticed any of the following changes in the past 6–12 months? (Select all that apply)

Diffuse hair thinning / increased shedding Nail brittleness, splitting, or peeling Hair loss at hairline or temples Nail ridging or discolouration None of the above

Wound Healing Scale – Rate how long a minor skin abrasion or blemish typically remains visible.

DLQI – Which of the following best describes your facial skin over the past 12 months?

Hydrated, firm, and elastic Mildly dry or reduced elasticity Noticeably drier with some crepiness Significantly aged beyond chronological expectation

Have you noticed any of the following ocular changes recently? (Select all that apply)

Near-vision deterioration (reading) Increased light sensitivity (photophobia) Dry eye / gritty or burning sensation New floaters or visual disturbance None of the above

Compared to 5 years ago, how would you describe your hand grip strength?

Noticeably stronger About the same Somewhat weaker Significantly weaker

Over the past 12 months, have you noticed any of the following? (Select all that apply)

Increased abdominal / central body fat Loss of muscle definition or size Both fat gain and muscle loss simultaneously Improved body composition No significant change

Have you undergone any objective biological ageing assessments in the past 12 months? (Select all that apply)

DNA methylation / epigenetic age test Comprehensive hormone and metabolic blood panel DEXA bone density and body composition scan Telomere length testing None – not tested

Do you currently experience any of the following? (Select all that apply)

Which of the following apply to your current lifestyle? (Select all that apply)

Current smoker Former smoker (quit within 5 years) High UV / sun exposure occupationally High travel frequency (>4 international trips/year) Shift work or highly irregular sleep schedule None of the above

3.4 – MOOD, COGNITION, AND SLEEP HEALTH ASSESSMENT

PHQ-2 – Over the past 2 weeks, how often have you had little interest or pleasure in doing things you normally enjoy?

None A little bit Most of the time All of the time

PHQ-2 – Over the past 2 weeks, how often have you felt down, depressed, or hopeless?

None A little bit Most of the time All of the time

GAD-2 – Over the past 2 weeks, how often have you felt nervous, anxious, or on edge?

None A little bit Most of the time All of the time

GAD-2 – Over the past 2 weeks, how often have you been unable to stop or control worrying?

None A little bit Most of the time All of the time

MoCA – Rate your ability to focus on a single complex cognitive task continuously for more than 60 minutes.

Have you noticed any change in your short-term memory, word-finding ability, or mental processing speed in the past 12 months?

Yes – noticeably worse Yes – mildly worse No change Actually improved

PSQI – How long does it typically take you to fall asleep once in bed with the intention to sleep?

Less than 15 minutes 16-30 minutes 31-60 minutes More than 60 minutes

PSQI – Do you wake consistently between 2 AM and 4 AM and experience difficulty returning to sleep?

Yes – most nights Occasionally No

ESS – How likely are you to doze off or fall asleep while sitting and reading?

Never Slight Moderate High

Do you use screens (phone, tablet, computer) within 60 minutes of your intended sleep time?

Yes – every night Yes – most nights Occasionally No – I maintain a screen-free wind-down

If you use a wearable device (Oura Ring, WHOOP, Garmin, Apple Watch), what is the trend in your 7-day average HRV?

Trending upwards Stable Trending downwards I don't know / I do not use a wearable tracker

3.5 – MUSCLE, METABOLISM, AND BODY COMPOSITION HEALTH ASSESSMENT

SARC-F – Strength – How much difficulty do you have lifting or carrying approximately 5 kg (e.g., a bag of groceries)?

No difficulty Some difficulty A lot of difficulty or unable

SARC-F – Assistance in walking – How much difficulty do you have walking across a room unaided?

No difficulty Some difficulty A lot of difficulty, use aids, or unable

SARC-F – Rise from a chair – How much difficulty do you have transferring from a chair or bed without using your arms?

No difficulty Some difficulty A lot of difficulty or unable without help

SARC-F – Stair climbing – How much difficulty do you have climbing a full flight of 10 stairs?

No difficulty Some difficulty A lot of difficulty or unable

SARC-F – Falls – How many times have you fallen in the past 12 months?

No falls Between 1 and 3 falls 4 or more falls

Do you consistently achieve a daily protein intake of at least 1.6 g per kg of body weight?

Yes – I track and consistently hit this target I aim for it but do not always achieve it No – my protein intake is likely below this I do not track my protein intake

FINDRISC – Do you experience a marked energy crash or urgent need to nap within 30–60 minutes of eating lunch?

Yes – consistently Yes – occasionally Rarely No

IPAQ – Which of the following best describes your typical weekly exercise pattern?

Sedentary – little to no structured exercise Light – 1–2 sessions per week Moderate – 3–4 sessions per week Active – 5 or more sessions per week

Metabolism - Do you have a current diagnosis of any of the following? (Select all that apply)

Type 2 diabetes or pre-diabetes Metabolic syndrome (diagnosed) Insulin resistance (diagnosed) Adrenal insufficiency or Cushing's syndrome Hypothyroidism or hyperthyroidism Polycystic ovary syndrome (PCOS) Active or past malignancy (any cancer) Other endocrine condition None of the above

Which of the following best reflects your daily nutrition and hydration patterns?

I drink ≥2 litres of water daily and eat whole foods predominantly I drink ≥2 litres daily but my diet is inconsistent My hydration is inconsistent but my diet is generally good Both my hydration and diet need significant improvement

4.1 – Confirmation

Confirm you are ready to finalise and submit this form to your practitioner.