Personal Information

Full Name *

Date of birth *

Height

Current Weight

Goal Weight

Primary Care Provider

Phone *

Email *

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By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from Peptide Doc Medical at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Nutrition & Lifestyle

How many meals do you typically eat daily?

Do you frequently experience:

Cravings

Late-night eating

Emotional eating

Binge eating

How often do you consume: *

Fast food
Sugary beverages
Processed snacks

How much water do you drink daily?

Do you currently exercise? *

Yes

If yes, what type of exercise and how often?

Weight Loss Goals

How much weight would you ideally like to lose?

What motivates you most to begin treatment now?

Medication Safety Screening

Have you ever had pancreatitis? *

Have you ever been diagnosed with medullary thyroid carcinoma? *

Do you have Multiple Endocrine Neoplasia Syndrome Type 2 (MEN2)? *

Do you experience severe gastrointestinal symptoms? *

Have you had allergic reactions to injectable medications? *

Do you have a history of severe depression or suicidal thoughts? *

Are you currently under the care of another weight loss clinic? *

Consent & Acknowledgment

I understand that:

Weight loss results vary between individuals.
Prescription medications require provider evaluation and approval.
Ongoing follow-up may be necessary for medication management and safety monitoring.
Healthy lifestyle modifications remain important during treatment.
Medications may carry risks and potential side effects which will be discussed by my provider.

Signature:

Clear

Date

Personal Information

Weight Loss History

Current Symptoms & Health Concerns

Nutrition & Lifestyle

Medical History

Current Medications & Supplements

Weight Loss Goals

Medication Safety Screening

Consent & Acknowledgment

I understand that: