Peptide & GLP Questionnaire

Please complete this form prior to your consultation. All information is kept confidential.

01Patient Information

Full Name *

Date of Birth *

Sex

Phone

Email *

02Primary Care Provider

PCP Name

PCP Phone

Clinic / Practice Name

Date of Last Physical

May We Request Records?

Yes No

03Medications & Allergies

Current Medications

Current Supplements

Known Allergies

05Medical History

Do you have, or have you ever been diagnosed with, any of the following?

Condition	Yes	No
History of pancreatitis Yes No
Gallbladder disease or removal Yes No
Personal or family history of medullary thyroid carcinoma (MTC) or MEN 2 Yes No
Gastroparesis Yes No
Eating disorder (current or past) Yes No
Diabetes (Type 1 or Type 2) Yes No
Hypoglycemia Yes No
Thyroid disorder Yes No
Kidney disease Yes No
Liver disease Yes No
Cardiac disease Yes No
Hypertension Yes No
Dyslipidemia (high cholesterol / triglycerides) Yes No
Blood clots, DVT, or pulmonary embolism Yes No
Active cancer Yes No
History of cancer (in remission) Yes No
Autoimmune condition Yes No
Psychiatric condition (anxiety, depression, etc.) Yes No
Sleep apnea Yes No
Pregnant, planning pregnancy, or nursing Yes No
Recent surgery (within past 6 months) Yes No
History of bariatric surgery Yes No

06Lifestyle

Tobacco or nicotine use

Yes No

Alcohol use (more than 7 drinks per week)

Yes No

Recreational drug use

Yes No

08Additional Information

Notes or Questions for the Provider

Patient Acknowledgment

I certify that the information provided is accurate and complete to the best of my knowledge. I understand that this questionnaire is for screening purposes and does not constitute medical advice. A physician will review my responses and determine eligibility for the requested therapies.

I acknowledge and agree to the above statement *

RegenOrtho Palm Beach delivers concierge orthopedic, podiatric, regenerative, and vein care with trusted expertise, innovative treatments, and compassionate support.

Peptide & GLP Questionnaire

Patient Acknowledgment

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Peptide & GLP Questionnaire

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