Peptide Questionnaire – BodyRejuvenation

Goals & Motivation

What are you hoping to improve with peptide therapy?

Select all that apply

Commitment & Lifestyle

How committed are you to optimizing your health right now?

Very committed – I’m ready to take action now
Somewhat committed – I’m gathering info before I commit
Just curious – I want to learn what’s possible

Please select all that apply

How would you describe your lifestyle right now?

High performance (CEO, athlete, high-output)
Busy & stressed – trying to stay ahead
Recovering from illness or injury
Focused on prevention and aging well
Other

Please specify

Health & Medical History

Have you used any of the following before?

Hormone therapy (e.g., testosterone, HRT)
Peptides or growth hormone boosters
NAD IVs or supplements
Other functional medicine protocols
None – this is my first time exploring these options

Select all that apply

Do you have any known autoimmune, cardiac, or metabolic conditions?

Yes
No
Not sure

We review all medical history before starting any treatment,

Please specify

Practical Fit

Are you currently working with a wellness doctor or clinic?

No – I’m looking for the right team
Yes – but I’m open to a second opinion
Yes – and I’m just comparing options

What’s your preferred method of peptide therapy?

Injections
Intranasal (non-injectable)
Not sure – I’d like to be guided by the doctor

Would you like to include lab testing to personalize your protocol?

Yes, I want to know what’s happening inside
Maybe – depends on the price and results
No thanks, just looking for a basic program

Lifestyle and Health:

Do you have any underlying health conditions?

Yes
No

e.g., thyroid issues, hormonal imbalances

Please specify

Do you take any medications regularly?

Yes
No

Please list them

Do you smoke?

Yes
No

Do you consume alcohol?

Yes
No

How would you describe your diet?

Balanced and healthy
Moderately healthy
Unhealthy

Do you stay active and prioritize healthy lifestyle habits like exercise and nutrition?

Yes
No

What interests you about non-surgical hair loss treatments?

Check all that apply

Please specify

Would you be open to exploring evidence-based, cutting-edge therapies for anti-aging and wellness?

Yes
No

Are you comfortable providing recent blood work or participating in a comprehensive health assessment?

Yes
No

Do you believe in a collaborative approach to healthcare, working with medical professionals to achieve your goals?

Yes
No

How much do you budget for your wellness each year?

Less than $1000
More than $1000. Less than $10,000
More than $10,000

We know this question may feel personal—but it's important. It helps us prioritize patients who are committed to long-term results, and tailor recommendations that make sense financially and medically.

In the last 3–6 months, what’s been the most frustrating part about your health, energy, or appearance? Please be as specific as possible

(numbers on the scale, lab results, clothes that don’t fit, comments from others, photos you didn’t like, etc.).

Can you describe a recent moment when this problem really bothered you or got in the way of your life? What happened, and how did it make you feel?

Enter your zip code

We need to make sure your state allows telehealth.

Name

First

Last

Email

Phone

How did you hear about us?

Please specify

Our clinic is located in Hallandale, Florida, are you nearby?

Yes
I can make it
No, but I'm OK with a virtual consultation

If you live far, we do offer virtual consultations