1

Patient Identification

First Name *

Last Name *

Date of Birth *

Phone *

Email *

Sex *

Female Male

2

Current Hormonal Health Status

Which best describes your period right now? *

I still get regular periods (or irregular but unchanged) My periods have become irregular I haven't had a period in over 12 months I no longer have periods due to a medical procedure I no longer have periods due to birth control

Date of last menstrual period (if applicable)

Are you currently on Hormone Replacement Therapy (HRT)?

Yes No

Have you had a hysterectomy or oophorectomy?

Yes No

3

Peptide Therapy History & Awareness

Have you previously used any peptide therapies?

Yes No

How did you hear about peptide therapy for hormonal health?

4

Requested / Recommended Peptide(s)

Check all that apply or have been recommended by your MetaPause provider:

BPC-157tissue repair / gut health Semaglutidemetabolic / weight mgmt PT-141sexual health / libido Tirzepatidemetabolic / weight mgmt CJC-1295 / Ipamorelingrowth hormone Epithalonanti-aging / telomeres Thymosin Alpha-1immune modulation

Other:

Primary treatment goal(s):

Peptide selection is subject to clinical review. Your MetaPause provider will evaluate your eligibility based on your medical history, current medications, and/or lab results, and will work with you to determine the safest and most effective protocol.

5

Medical History — Peptide-Specific Screening

Please answer all questions. These are required for safe peptide prescribing beyond the standard medical intake.

Do you have a personal history of any cancer?

Yes No

Do you have a family history of cancer (first-degree relative)?

Yes No

Have you ever been diagnosed with a pituitary disorder?

Yes No

Do you have a history of blood clots or clotting disorders (DVT/PE)?

Yes No

Have you been diagnosed with diabetes (Type 1 or Type 2)?

Yes No

Do you have any active autoimmune conditions?

Yes No

Do you have active liver or kidney disease?

Yes No

Have you had any organ transplants?

Yes No

Are you currently pregnant, breastfeeding, or planning pregnancy?

Yes No

Do you have a known allergy to mannitol, glycine, or bacteriostatic water?

Yes No

If you answered YES to any of the above, please provide details:

6

Hormone Replacement Therapy (HRT) — Detailed Screening

Complete this section if you are currently using, have previously used, or are considering HRT in conjunction with peptide therapy.

Current HRT Status

Currently on HRT Previously on HRT (discontinued) Considering HRT Never used HRT

Other:

HRT Dosage & Duration

Current HRT medication(s) & dosage:

Duration on current HRT regimen:

Prescribing provider for HRT:

HRT Response & Side Effects

Have your menopausal symptoms improved since starting HRT?

Yes No

Have you experienced any breakthrough bleeding or spotting on HRT?

Yes No

Have you experienced breast tenderness, bloating, or headaches on HRT?

Yes No

Have you had any mood changes (anxiety, depression, irritability) since starting HRT?

Yes No

Have you had any blood clots, cardiovascular events, or stroke while on HRT?

Yes No

Has your provider adjusted your HRT dosage in the last 6 months?

Yes No

If you answered YES to any of the above, please provide details:

HRT & Peptide Interaction Awareness

Please read and check each statement:

I understand that certain peptides may interact with or augment the effects of HRT, and that dosage adjustments to either therapy may be necessary. I agree to inform my MetaPause provider of any changes to my HRT regimen during peptide therapy. I understand that combining growth hormone-releasing peptides (e.g., CJC-1295/Ipamorelin) with HRT may require additional monitoring of IGF-1 and hormone levels. I acknowledge that metabolic peptides (e.g., Semaglutide, Tirzepatide) may affect hormone absorption and metabolism, and that my provider will monitor accordingly.

HRT Lab Monitoring

If on HRT, the following labs may be required prior to or during peptide therapy. Check if completed within the past 6 months:

7

Current Medications & Supplements (Peptide-Relevant)

List all medications, supplements, and peptides you are currently taking. Include dosage and frequency.

Medication / Supplement	Dosage	Frequency	Reason / Condition

Are you currently using any injectable medications?

Yes No

Are you taking blood thinners or anticoagulants?

Yes No

Are you taking insulin or other glucose-lowering medication?

Yes No

8

Recent Lab Work & Baseline Testing

Certain peptides require baseline labs. Please indicate which of the following have been completed within the past 6 months.

Date of most recent lab work:

Are you willing to complete any required labs prior to starting therapy?

Yes No

9

Lifestyle & Symptom Context

Primary symptoms you are seeking to address (check all that apply):

Other symptoms not listed:

10

Self-Injection Readiness Assessment

Have you ever self-administered an injection (e.g., insulin, fertility meds)?

Yes No

Are you comfortable with subcutaneous self-injection?

Yes No

Would you like injection training from your MetaPause provider?

Yes No

Preferred administration method (if applicable):

Subcutaneous injection Oral / sublingual Nasal spray No preference

11

Informed Consent Acknowledgments

Please read and check each statement below:

I understand that peptide therapies are prescribed off-label and may not be FDA-approved for my specific condition. I understand the potential side effects and risks have been or will be discussed with me prior to treatment. I agree to comply with all recommended lab monitoring and follow-up appointments. I understand that peptides will be sourced from a licensed U.S. compounding pharmacy. I acknowledge that results vary and peptide therapy is part of a comprehensive wellness approach. I agree to notify MetaPause immediately if I experience any adverse effects during therapy.

13

Patient & Provider Signatures

Patient Attestation

I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize MetaPause and its affiliated providers to use this information for my care.

Patient Signature

Date