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Patient Information
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Phone Number
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Patient Address
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Height
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Weight
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Current Medications
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Current Supplements
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Medical History
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Allergies
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Reasons For Seeking Peptide Therapy
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Reasons For Seeking Peptide Therapy
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Past Peptide History
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Describe which peptides you have used and your experience?
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Current Symptoms
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Previous Treatments
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Medications
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Medications Free Text
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Supplements
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Supplements Free Text
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Lifestyle Changes
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Lifestyle Changes Free Text
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Current Lifestyle Habits
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Diet
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Exercise
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How many days a week do you currently exercise?
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Stress
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Sleep (hours/night)
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Peptide Therapy Goals
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Peptide Therapy Goals
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Risks and Benefits
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Risks and Benefits
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Peptide Therapy Informed Consent
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Recommended Treatment:
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BPC-157 (General Wellness)
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BPC-157 (Injury Recovery/Post-op)
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PT-141(Men)
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PT-141 (Women)
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Semorelin (GH/IGF-1 Deficiency)
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Sermorelin (Weight Loss)
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Ipamorelin (GH/IGF-1 Deficiency)
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Ipamorelin (Weight Loss)
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Ipamorelin/CJC-1295
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DSIP (Delta Sleep Inducing Peptide)
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GHK-Cu
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Lab Order for GH-Monitoring
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Month 1
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Month 2/3
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Month 4-6
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Provider Narrative
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Provider Narrative
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Peptide Consent
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