Registration Form ‹ Peptides Direct

I am over 18 years old *

YES

Birth Date *

Sex *

Do you give Peptides Direct Medical Team Permission to speak to your GP directly regarding any medical concerns?

NO
YES

Date of Last GP Check Up

Name of GP Clinic

GP Clinic Contact Number

Primary GP Physician

GP Clinic Address

Weight *

kg

Height *

cm

Are you a Smoker? *

Do you drink Alcohol? *

Health Goals

Please indicate your health goals by ticking the boxes below:

WEIGHT LOSS/FAT METABOLISM

MUSCLE GAIN + STRENGTH

MUSCLE + INJURY RECOVERY

ANTI AGEING

LIBIDO + SEXUAL HEALTH

MENTAL ALERTNESS

MEDICAL INFORMATION

Do you have any allergies? *

NO
YES

If yes, please give more details

Do you have any current medical conditions? *

NO
YES

If yes, please give more details

Please list any past medical conditions:

Are you taking any prescribed medication? *

NO
YES

If yes, please give more details

Are you taking any supplements or over the counter medications NOT prescribed by a doctor? *

NO
YES

If yes, please give more details

Do you have or have you ever had any of the following?

If you answer ‘yes’ to any of the below, please give more detail)

Reduced Appetite *

NO
YES

Please give more details

Unexplained Weight Loss *

NO
YES

Please give more details

Night Sweats/Fevers *

NO
YES

Please give more details

Any Lumps (breast, armpit, groin area) *

NO
YES

Please give more details

Fatigue *

NO
YES

Please give more details

Anxiety *

NO
YES

Please give more details

Depression *

NO
YES

Please give more details

Have you had any surgical procedures in the past 4 weeks or are planning on having any procedure done in the next 4 weeks? *

NO
YES

If yes, please give more details

Have you ever been diagnosed with cancer? *

NO
YES

If yes, please give more details

Do you have a family history of cancer? *

NO
YES

If yes, please give more details

Who died and at what age?

What type of cancer did they have?

Have you been investigated and cleared?

Has anyone else in your family been investigated?

What primary (if known)?

What was their treatment for it?

Have you been diagnosed with epilepsy? *

NO
YES

If yes, please give more details

Have you been diagnosed with diabetes or abnormal blood sugar levels? *

NO
YES

If yes, please give more details

Last Blood Pressure (Example 120/80)

Last Pulse

Do you have a history of high blood pressure? *

NO
YES

Have you ever had a stroke? *

NO
YES

If yes, please give more details

Have you been diagnosed with any heart conditions? *

NO
YES

If yes, please give more details

Do you suffer from chest pains, palpitations (irregular or fast heart beat), shortness of breath with exercise? *

NO
YES

If yes, please give more details

Are you currently trying to conceive? *

NO
YES

(For Men) Do you have trouble maintaining or getting an erection?

NO
YES

(For Men) Do you have concerns with pre-ejaculation?

NO
YES

(For Men) Do you have concerns around libido?

NO
YES

(For Women) Are you currently breast feeding?

NO
YES

(For Women) Are you currently on contraception?

NO
YES

If yes, please give more details

(For Women) Do you have concerns around libido?

NO
YES

Do you suffer from any joint problems? *

NO
YES

If yes, please give more details

Do you suffer from any muscular, connective tissue or ligament injuries/conditions? *

NO
YES

If yes, please give more details

Is there any other medical information you would like the doctor to know? *

NO
YES

If yes, please give more details

Billing Phone *

Anti-Spam *

NO
YES

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