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
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01 — YOUR BASELINE
What is your height?
cm
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01 — YOUR BASELINE
What is your current weight?
kg
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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 - medications
Yes - food
Yes - other
02 — HEALTH BACKGROUND
Are you currently pregnant?
No
Yes
02 — HEALTH BACKGROUND
Are you currently breastfeeding?
No
Yes
03 — PRIMARY HEALTH OBJECTIVES
What is your main health goal?
Healthy aging & longevity
Build muscle & recover better
Heal injuries & reduce pain
Improve metabolism & reduce belly fat
Improve sleep & reset your body clock
04 — HEALTHY AGING & LONGEVITY
How would you rate your energy most days?
Very good
Good
Moderate
Low
04 — HEALTHY AGING & LONGEVITY
Have your recovery, resilience, or stamina declined recently?
No
Slightly
Moderately
Significantly
04 — HEALTHY AGING & LONGEVITY
How often do you get colds, flu, or infections?
Rarely
1-2 times per year
3-4 times per year
Frequently
04 — HEALTHY AGING & LONGEVITY
Do you deal with ongoing inflammation, aches or stiffness?
No
Occasionally
Often
Constantly
05 — LONG-TERM HEALTH
Is your focus long-term health optimization rather than treating a disease?
Yes
Somewhat
No
FINAL STEP
Where can we reach you?
Please provide your name and mobile number.
Full Name
Mobile Number
Submit Assessment
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