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Online Patient Intake Form – NAD+ & Peptide Therapy

Personal Information
Full Name*
Date of Birth*
Height*
Gender*
Current Weight (lbs)*
Desired Weight (lbs)*
Phone Number*
Email Address*
State*
City*
Fill required fields
Section 1: Symptom Assessment
Please check all symptoms that apply to you within the past 6 months.
Energy & Fatigue
Cognition & Mood
Sleep Quality
Metabolism & Weight
Hormonal Changes
Section 2: Lifestyle & Health History
Do you currently exercise?*
If yes, how many days per week?
If yes, please describe:
Do you smoke or vape?*
Do you drink alcohol regularly?*
Medical Conditions (Check all that apply):*
Current Medications/Supplements
Have you ever been diagnosed with hormonal imbalance or low testosterone? *
Have you ever used peptide therapy or NAD+ before? *
If yes, please list which ones and duration of use
Section 3: Treatment Goals
What would you like to achieve with NAD+ and peptide therapy? (Check all that apply)
Consent & Acknowledgment
Consent & Acknowledgment*
By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I understand that this questionnaire is used to determine candidacy for NAD+ and peptide therapy and does not replace a medical diagnosis or physician consultation.
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