ELIGIBILITY ASSESSMENT Peptide Therapy

01 — YOUR BASELINE

Where are you located?

Abu Dhabi Dubai Sharjah Other Emirate

01 — YOUR BASELINE

What is your gender?

Male Female

01 — YOUR BASELINE

How old are you?

years

01 — YOUR BASELINE

What is your height?

cm

01 — YOUR BASELINE

What is your current weight?

kg

01 — YOUR BASELINE

Which body shape feels closest to yours today?

Athletic Lean Normal Soft Abdominal Generalized obesity

02 — HEALTH BACKGROUND

How active are you in a typical week?

Sedentary Mostly sitting with little to no exercise Light activity Occasional walking or movement, without a regular workout routine Moderate Walking, cycling, or light workouts 2-3 times per week Active Cardio or strength training 3-5 times per week Very active Training almost daily or doing high-intensity workouts or sports

02 — HEALTH BACKGROUND

Do you have any ongoing medical conditions?

No Yes

02 — HEALTH BACKGROUND

Do you take any regular medications?

No Yes

02 — HEALTH BACKGROUND

Do you have any known allergies or sensitivities?

No known allergies Yes with medications Yes with food Yes other

02 — HEALTH BACKGROUND

Are you currently pregnant?

No Yes

02 — HEALTH BACKGROUND

Are you currently breastfeeding?

No Yes

03 — PROTOCOL FOCUS

What is your primary goal?

Select the area that matters most to you right now.

Recovery & Tissue Repair Immune & Gut Health Skin & Aesthetic Health Growth & Performance Hormonal Wellness General Optimization

04 — RECOVERY & TISSUE REPAIR

What best describes your situation?

This helps us narrow down the best peptide for you.

Chronic tendon or ligament issue (tennis elbow, plantar fasciitis, rotator cuff) Muscle strain or tear recovery Joint pain or cartilage issue Post-surgical healing

04 — IMMUNE & GUT HEALTH

What gut issues are you dealing with?

This helps us narrow down the best peptide for you.

IBS or chronic digestive issues Suspected leaky gut or food sensitivities NSAID – related stomach damage General gut inflammation

04 — SKIN & AESTHETIC HEALTH

What's your top skin/aesthetic concern?

This helps us narrow down the best peptide for you.

Fine lines, wrinkles, or loss of elasticity Hair thinning or early hair loss Slow wound healing or scarring Overall skin quality and aging

04 — GROWTH & PERFORMANCE

What's holding you back?

This helps us narrow down the best peptide for you.

Slow recovery between sessions Nagging injuries that won’t resolve Inflammation and joint wear Overall performance plateau

04 — HORMONAL WELLNESS

What best describes your concern?

This helps us narrow down the best peptide for you.

Low libido or reduced desire Arousal or response issues Want to improve sexual wellness overall

04 — GENERAL OPTIMIZATION

What would make the biggest difference?

This helps us narrow down the best peptide for you.

Better sleep quality More energy and vitality Body composition (lean mass, fat loss) Slow down aging

05 — PROTOCOL DETAILS

How much is this affecting your daily life?

No wrong answers — just helps us understand your situation.

Mild – Noticeable but manageable Moderate – Affecting quality of life Significant – Major daily impact Severe – limiting what I can do

05 — PROTOCOL DETAILS

How long have you been dealing with this?

This helps us calibrate expectations for your protocol.

A few weeks Several months 1-2 years 3+ years

05 — PROTOCOL DETAILS

Have you used peptides before?

This helps us tailor the level of detail in your results.

Never – this is all new to me I’ve researched but never tried I’ve used peptides from an online source I’ve used peptide through a medical provider

05 — PROTOCOL DETAILS

Are you currently on any hormone or optimization therapy?

Peptides often complement other protocols.

Yes, I am an Arabian Homehealth patient Yes, at another provider No, but I’m interested No, just interested in peptides

05 — PROTOCOL DETAILS

How important is keeping your protocol simple?

Some protocols combine multiple peptides into one injection.

Very – I want the fewest injections possible Somewhat – I’m flexible Not important – I’ll do what works best

FINAL STEP

Where can we reach you?

Please provide your name and mobile number.

Full Name

Mobile Number