Sample Questionnaire General New Patient Questionnaire Please complete this health background questionnaire before your telehealth visit. Your provider will use it to understand your medical history, current health concerns, and whether peptide therapy or other prescription options may be appropriate. Basic demographic details such as date of birth may already be available from your pre-screening form. Visit Goals What are the main health goals or concerns you want to discuss during this telehealth visit? * Which services or topics are you interested in discussing? General telehealth consultation Peptide therapy Weight management Metabolic health Energy or fatigue Sleep Muscle, joint, or recovery support Hormone or sexual health Skin, hair, or healthy aging Other If you selected peptide therapy or other prescription treatment, what product or treatment are you hoping to discuss? Have you previously used prescription peptides, GLP-1 medications, or injectable wellness therapies? * No Yes Not sure If yes, list what you used, approximate dates, dose if known, benefits, and any side effects. Current Health Information Current height * Feet Inches Current weight * List all current prescription medications, over-the-counter medicines, supplements, and vitamins. * List any medication, food, or environmental allergies and describe the reaction. * What medical conditions have you been diagnosed with? * List prior surgeries, hospitalizations, or major injuries. Have you had any recent lab work, imaging, or specialist evaluations your provider should know about? Peptide And Prescription Safety Screening Have you ever had any of the following? Select all that apply. * Pancreatitis Gallbladder disease or gallstones Medullary thyroid cancer Multiple Endocrine Neoplasia syndrome type 2 (MEN2) Personal history of cancer Active cancer treatment Seizure disorder Severe kidney disease Severe liver disease Heart attack, stroke, or blood clot Eating disorder None of the above If you selected any condition above, provide details. Are you pregnant, trying to become pregnant, breastfeeding, or could you be pregnant? * No Yes Not applicable Prefer to discuss with provider Do you have a personal or family history of thyroid cancer or MEN2? * No Yes Not sure Have you ever had a serious reaction to an injectable medication, peptide, or compounded prescription? * No Yes Not sure Describe any medication side effects or reactions your provider should consider. Family And Social History List significant family medical history. Do you currently use tobacco or nicotine products? * No Yes Former user How often do you drink alcohol? * Never Rarely 1-3 drinks per week 4-7 drinks per week More than 7 drinks per week Do you use cannabis, recreational drugs, or non-prescribed controlled substances? * No Yes Prefer to discuss with provider Describe your typical diet, activity level, sleep, and stress level. Telehealth Visit Details What questions do you want to make sure the provider answers during your visit? Preferred pharmacy name and city/state Are you physically located in a state where this telehealth visit is permitted, and can you provide your current location if asked? * Yes No Not sure I understand that completing this questionnaire does not guarantee a prescription. The provider will determine whether treatment is appropriate after clinical review. I certify that the information I provided is accurate and complete to the best of my knowledge. Submit Loading questionnaire…
