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First Name
Last Name
Email
Contact Number
Password
Confirm Password
Date of Birth
Gender assigned at birth
Male
Female
Preferred doctor
Male
Female
No preference
I confirm that I am over 18 years old
Primary reason for seeking peptide guidance (select all that apply)
Height (cm)
Weight (kg)
Typical physical activity
Select activity level
Sedentary
Lightly active
Moderately active
Very active
Athlete / elite sport
Previous injuries or surgeries involving bones, ligaments, tendons, or muscles?
No
Yes
Diagnosed joint conditions or ongoing joint-related issues?
No
Yes
Have you ever experienced any of the following?
History of thyroid disease?
No
Yes — hypothyroidism
Yes — hyperthyroidism
Other thyroid condition
History of pancreatic disease?
No
Yes
Have you ever been diagnosed with:
Significant disease affecting:
History of cancer, tumors, or unexplained growths?
No
Yes
Currently pregnant or planning pregnancy in next 3 months?
No
Yes
Not applicable
Sexual health concerns:
Diagnosed or treated for:
Sleep difficulties:
Diagnosed gastrointestinal conditions or ongoing digestive issues?
No
Yes
Current peptide use
Peptides of interest
Medical Documentation (Optional)
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Additional Information (Optional)
I confirm that the information provided in this health questionnaire is true and accurate to the best of my knowledge. I understand that this assessment is used to support consultation and guidance and does not replace personalised medical care or emergency medical services.
I agree to the above acknowledgement and consent
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