EmailMe Form - Health and Lifestyle Questionnaire

Name *

First Last

Phone *

### - ### - ####

Email *

Date of Birth *

MM / DD / YYYY

Weight *

Height *

BF% (if known - How was it measured)

Location (San Diego or Remote) *

How'd you find us?

Are you currently working with a trainer or coach? if so, what capacity?

Section 2: Primary Goals

Select your goals *

Section 3: Current Health Status

Check ALL That Apply *

Current Medications (list all, including dose if known)

Known Allergies (medications & substances)

Active Injuries &/or Surgeries in the last 12 mos

Family Cancer History

Family History of Cardiovascular Disease

Section 4: Hormones

Currently on TRT or HRT

List all hormonal medications, doses, protocols

Last Hormone Panel (Labwork)

MM / DD / YYYY

Experiencing ANY of the Following Symptoms

Section 5: Recent Labs

Check ALL That Apply

Lab Upload 1

Lab Upload 2

Lab Upload 3

Any Labs Your Doctor Flagged?

Section 6: Peptide History

Have you take peptides before? *

Which peptides? (dosage and duration)

List ANY negative side effects that you experienced.

Section 7: Current Supplements

List ALL (dosage, uses, etc)

Select if ANY apply? *

Section 8: Training and Lifestyle

Training Frequency *

Training Style *

Sleep Quality ( 1=bad, 10 = amazing) *

Alcohol Use *

Tobacco or Vaping *

Diet Approach *

Section 9: Peptide Interest

Select all peptides you want to learn about

Other Peptides or Compounds (not listed here)

Anyting specific you'd like to cover in your consultation?

Consent and Disclaimer

Important: This questionnaire is for n-of-1 educational research purposes only. It does not constitute medical advice, diagnosis, or an individualized treatment protocol. Over 40 Fitness SD does not prescribe, sell, or administer peptides or pharmaceutical compounds. Any information shared in consultation is educational in nature and does not replace the advice of a licensed physician or qualified healthcare provider.

ALL Need to be Checked *

I understand this inquiry is for educational research purposes only and does not constitute medical advice

I am not currently pregnant or breastfeeding

I understand peptide education does not replace physician supervision

I consent to follow-up contact from Over 40 Fitness SD

Signature

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If the signature wont work on your device, type your name here

Date Time *

MM / DD / YYYY