Confidential Health Intake

This questionnaire helps us understand your complete health picture before your consultation. Your responses are kept strictly confidential and used solely to build a personalized longevity protocol. The more thorough you are, the better we can serve you — including checking for medication interactions and tailoring recommendations to your specific needs.

Contact Information

Where we'll send your protocol and how to reach you.

Full Name *

Email *

Phone (optional)

Age *

Biological Sex *

Location (City, State/Country)

Body Composition

This helps us understand your overall health profile and recommend appropriate dosing. All information is kept confidential.

Height *

Current Weight *

Body Fat % (if known)

Weight Goal

Medical History

This is essential for checking medication interactions and ensuring safe protocol recommendations. All information is confidential.

Known Medical Conditions / Diagnoses *

Family Medical History

Previous Surgeries

Known Allergies

Medications & Supplements

Critical for interaction checking. Even over-the-counter items can interact with peptides and supplements. Please be thorough.

Current Prescription Medications *

Over-the-Counter Medications

Current Supplements *

Previous Experience with Peptides?

If yes, which peptides/compounds have you used?

Lifestyle & Habits

Your daily habits significantly impact protocol design.

Diet Type

Exercise Frequency

Exercise Type

Hours of Sleep per Night

Sleep Quality

Poor Fair Good Excellent

Stress Level (1 = relaxed, 10 = overwhelmed)

RelaxedOverwhelmed

Alcohol Consumption

Tobacco / Nicotine Use

Recreational Drug Use

Caffeine Intake

Protocol Preferences

Helps us tailor our recommendations to your comfort level and budget.

Monthly Budget Range for Protocol

Preferred Delivery Methods

Oral (capsules, tablets) Injectable (subcutaneous) Nasal spray Topical (cream, gel) Sublingual / troche Open to all methods

Comfort Level with Research Peptides

Additional Information

Anything Else You'd Like to Share?

How Did You Hear About Us?

Acknowledgment & Consent

Educational Purpose: The information provided by Phoenix Longevity Research & Consulting is for educational and research purposes only. It is not intended as medical advice, diagnosis, or treatment. Always consult with a qualified healthcare provider before starting any peptide protocol, supplement regimen, or longevity intervention — especially if you have existing medical conditions or take prescription medications.

Privacy: Your intake information is kept confidential and used solely to prepare your personalized protocol. We do not sell or share your personal health information with third parties.

No Medical Relationship: Completing this form does not establish a doctor-patient relationship. Phoenix Longevity Research & Consulting provides research, education, and consulting services — not medical treatment.

I understand this is educational and not medical advice. * I consent to my health information being used to prepare my protocol. * I understand this does not establish a doctor-patient relationship. *

Your responses will be sent securely to info@phxlr.com. We typically respond within 24 hours.

Intake Received

Thank you for completing your health intake. We'll review your information, check for any medication interactions, and prepare a personalized protocol. Expect a response within 24 hours.

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