Sermorelin Assessment

Patient Profile

Full Name *

Email Address *

Phone Number *

Date of Birth *

Gender *

Female Male

Are you currently pregnant or breastfeeding? *

Yes No

Height and Weight *

ft

in

lbs

BMI: Enter height and weight above

Have you previously received Sermorelin injections? *

Yes No

If yes, what dose? *

Are you currently receiving Sermorelin injections elsewhere? *

Yes No

If yes, what dose? *

Do you currently have cancer or a history of cancer? *

Yes No

Do you have any history of thyroid issues (such as hypothyroidism)? *

Yes No

Is it controlled? *

Yes No

What is your exercise level? *

High Low Moderate

Do you have any allergies? *

Yes No

If yes, please list your allergies *

Do you currently use tobacco or vape? *

Yes No

What type of tobacco/vaping products and how frequently? *

Are you currently receiving chemotherapy? *

Yes No

Are you currently experiencing depression with history of suicidal attempts, thoughts, or ideation? *

Yes No

Address *

Address 2

City *

State *

Postal Code *

Upload government ID (driver's license) for identity verification *

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