Project Preservation — Clinical Intake

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Let's start with you.

Basic information used to create your clinical record.

Legal first name *

Legal last name *

Date of birth *

Biological sex at birth *

Email address *

Mobile number *

State of residence * Your provider must be licensed in your state

Emergency contact name

Emergency contact relationship

Emergency contact phone

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Body composition.

Used to calculate clinical dosing thresholds and assess baseline metabolic status.

Height — feet *

Height — inches *

Weight (lbs) *

How would you describe your current body composition? *

Lean — at or below my goal weight Slightly above my goal — 10–20 lbs Moderately above my goal — 20–50 lbs Significantly above my goal — 50+ lbs

Has your weight changed significantly in the past 12 months? *

Stable (within 10 lbs) Gained more than 10 lbs Lost more than 10 lbs — intentionally Lost more than 10 lbs — without trying

Please describe the unintentional weight loss. ⚠ Yellow flag — provider review before peptide initiation

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Medical history.

Select anything that applies to you, past or present. This directly shapes your protocol.

Any other diagnoses your provider should know about?

Do you have a primary care physician or specialist currently managing any of these conditions? *

Yes

No

Physician name and specialty (optional)

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What you're currently taking.

Interactions between peptides and certain medications require provider attention. Please be thorough.

Are you currently taking any prescription medications? *

Yes

No

List all current prescription medications * Include name, dose, and frequency if known

Are you currently taking insulin or any injectable diabetes medication? * ⚠ Potential interaction with GLP-1 and glucose-regulating peptides

Yes

No

⛔ Red flag — provider review required before GLP-1 initiation

Please specify medication and current dose

Are you taking any blood thinners or anticoagulants? * e.g. Warfarin, Eliquis, Xarelto, Plavix, daily aspirin 325mg+

Yes

No

⚠ Yellow flag — relevant for peptide injection site guidance

Medication and reason

Are you taking corticosteroids or immunosuppressants? * e.g. Prednisone, Methotrexate, Tacrolimus, biologics

Yes

No

⚠ Yellow flag — may affect immune-modulating peptide protocols

Medication and indication

Are you currently taking any supplements or OTC vitamins? *

Yes

No

List current supplements Include dose and frequency if known

Do you have any known drug allergies? *

Yes

No

Please list allergies and reactions

Any known allergies to preservatives, rubber, latex, or injection materials?

Yes

No

⚠ Yellow flag — relevant for compounded peptide vial selection

Please describe

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Reproductive health.

Hormonal status significantly affects peptide protocol design and safety thresholds.

Are you currently pregnant or trying to conceive? *

Yes

No

⛔ Red flag — peptide therapy is contraindicated during pregnancy and active conception attempts. Your intake will be paused and a provider will follow up.

Are you currently breastfeeding? *

Yes

No

⛔ Red flag — provider review required. Most peptide protocols are not recommended during lactation.

What is your current menstrual status? *

Regular cycles Irregular cycles Perimenopause Menopause (12+ months without a period) Surgical menopause Not applicable / on hormonal contraception that suppresses periods

Are you currently on hormonal therapy or contraception? * e.g. birth control pill, IUD, HRT, testosterone, DHEA

Yes

No

Please specify

Have you been diagnosed with PCOS, endometriosis, or another hormonal condition?

Yes

No

Diagnosis and current management

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Surgical history.

Prior surgeries, especially GI-related, affect peptide tolerability and dosing.

Have you had any surgeries in the past? *

Yes

No

Please list surgeries, approximate year, and any complications

Have you ever had bariatric or weight-loss surgery? * e.g. gastric sleeve, gastric bypass, lap band

Yes

No

⚠ Yellow flag — GLP-1 protocols require modified initiation approach

Type of procedure and year

Have you received any cancer-related treatments (chemotherapy, radiation, immunotherapy)?

Yes

No

⚠ Yellow flag — history reviewed by provider before growth-factor peptides

Type of cancer, treatment, and year last treated

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Family health history.

Genetic predispositions can influence which protocols are appropriate for long-term use.

Do any of the following apply to close family members (parents, siblings)? * Select all that apply

None of the below Thyroid cancer or medullary thyroid carcinoma Multiple Endocrine Neoplasia type 2 (MEN2) Pancreatitis Pancreatic cancer Type 2 diabetes Early heart disease (under age 60) Other cancer (please specify below)

Anything else in your family history relevant to your health?

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Digestive and mental health.

GI tolerance and mental health baseline are both relevant to protocol selection and support planning.

Do you have a history of any of the following GI conditions? * Select all that apply

None GERD / acid reflux (chronic) IBS or functional GI disorder Crohn's disease or ulcerative colitis Gastroparesis Gallbladder disease or history of gallstones Celiac disease

How would you describe your current digestive health?

No issues — digestion is comfortable and regular Occasional bloating, discomfort, or irregular bowel Frequent GI symptoms that affect my daily life

Do you have a history of any of the following mental health conditions? * This helps us select protocols least likely to affect mood and sleep architecture

Are you currently working with a therapist, psychiatrist, or mental health provider?

Yes

No

How is your sleep? *

Good — 7–9 hours, feel rested Moderate — difficulty falling or staying asleep Poor — chronic sleep issues affecting function

Have you been diagnosed with sleep apnea? *

Yes

No

Are you currently using CPAP or other treatment?

Yes

No

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How you live.

Lifestyle context helps us personalize your protocol and set realistic expectations.

How would you describe your current exercise routine? *

Sedentary — minimal intentional movement Light — 1–2 days per week, walking or casual activity Moderate — 3–4 days per week, mixed cardio and strength Active — 5+ days per week, structured training Performance athlete — competitive or high-intensity training

What best describes your primary exercise type?

How would you describe your diet? *

Balanced — no specific protocol, varied foods High protein / performance-focused Low carbohydrate or ketogenic Intermittent fasting Plant-based or vegan Inconsistent — working on improving

How often do you consume alcohol? *

Never Rarely — a few times per month or less Moderate — a few times per week, 1–2 drinks Frequent — daily or near daily Heavy use — 4+ drinks per day

Do you currently smoke or use tobacco products? *

Never smoked Former smoker — quit more than 1 year ago Recently quit — within the past year Currently smoke — less than half a pack per day Currently smoke — half a pack per day or more Vaping or e-cigarettes

Do you currently use recreational drugs or cannabis? * This information is strictly clinical and confidential. It directly informs dosing decisions.

No Cannabis — occasional use Cannabis — regular use Other recreational substances

Please describe (confidential)

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Prior experience.

Your history with peptides and GLP-1s shapes where we start and what to watch for.

Have you previously used any GLP-1 medications? * e.g. Semaglutide (Ozempic, Wegovy), Tirzepatide (Mounjaro, Zepbound), Liraglutide

Yes

No

Which medication(s), highest dose reached, and reason for stopping?

Did you experience any side effects?

No notable side effects Nausea or vomiting Diarrhea or constipation Fatigue Mood changes Hair loss Muscle loss or weakness Abdominal pain consistent with pancreatitis Other

Have you previously used any peptides? * e.g. BPC-157, TB-500, Ipamorelin, CJC-1295, PT-141, Epithalon, MOTS-C

Yes

No

Which peptides, duration of use, and results?

Did you experience any adverse reactions?

Yes

No

⚠ Yellow flag — prior adverse peptide reactions reviewed by provider

Please describe

Are you currently on a protocol with another provider or telehealth service? *

Yes

No

⚠ Yellow flag — concurrent protocols require provider coordination

What are you currently prescribed?

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What you're here for.

Your goals guide protocol selection. Be specific — our providers read every word.

Is there a specific outcome that is most important to you right now? * This becomes your primary treatment objective

What is your timeline expectation?

I want to see results in 1–3 months I'm approaching this as a 3–6 month commitment I'm interested in long-term protocol and maintenance I'm open to whatever my provider recommends

How comfortable are you with self-injection? *

Experienced — I have self-injected before Open — I'm willing to learn Hesitant — I'd like guidance before committing No — I prefer non-injectable options where available

Is there anything else your provider should know before designing your protocol?

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Review and consent.

Please read the statements below carefully. Your signature confirms accuracy and authorizes clinical review.

Full legal name — typed signature * Type your full name as it appears on your intake to confirm agreement

Today's date *

I have read and agree to all of the above statements. I confirm this intake is submitted voluntarily and accurately.