Sermorelin Health Assessment Form

Before we can continue, we need to collect a few pieces of information about your health to make sure Sermorelin is right for you.

We are evaluating your eligibility for Sermorelin, which may help manage conditions like low energy levels and fatigue, and may improve cognitive function and focus. The following questions provide critical information to ensure our clinicians can deliver safe and effective care tailored to your needs. By continuing, you confirm your interest in proceeding with this assessment.

What is your date of birth?(Required)

Month

Day

Year

What was your sex assigned at birth?(Required)

Male

Female

Please let us know if any of the following apply.(Required)

Please fill out other fields.

Current Height:

Feet:(Required)

Inches:(Required)

Current weight in pounds:(Required)

What are your main goals with Sermorelin?

Improve energy & stamina

Enhance muscle recovery

Optimize body composition (lose fat, gain lean muscle)

Boost sleep quality

Support healthy aging

None of the above

Please select all that apply

Do you have any of these conditions?(Required)

Please check all that apply.

Active cancer (any type)

History of brain tumor or pituitary adenoma

Uncontrolled diabetes (A1c > 9%)

Severe untreated sleep apnea

None of the above

Do you have any diagnosed endocrine (hormone) disorders?(Required)

Please check all that apply.

Pituitary issues (adenoma, hypopituitarism)

Thyroid problems (Hashimoto’s, Graves’ disease, hypo/hyperthyroidism)

Adrenal issues (Cushing’s, Addison’s)

PCOS or diabetes

None of the above

Are you taking daily oral steroids or any other medication ?(Required)

Including Prednisone, Methylprednisolone, Clobetasol propionate, and Hydrocortisone

Steroid medication (by mouth)

Other medications or supplements

I do not take any medications

Please tell us more about the steroid(s) or other medications/supplements you're currently taking.(Required)

Steroid name, dose and frequency, and reasons for each medication's use. Please be as detailed as possible to prevent delays in your assessment evaluation.

Please tell us more about the other medications/supplements you're currently taking.(Required)

Medication/supplement name, dose and frequency, and reasons for each medication's use. Please be as detailed as possible to prevent delays in your assessment evaluation.

Have you ever taken growth hormone therapy before?(Required)

Yes

rhGH, sermorelin, CJC-1295, ipamorelin, MK-677, etc.

Please tell us more about the previous growth hormone treatment you have taken.(Required)

Please list each treatment, how long you took it, as well as any side effects you may have experienced (e.g., joint pain, swelling)

Do you have a history of allergic reactions to the following medications or foods?(Required)

Fruits

Medications

Other

No Known Allergies

You selected you have a history of allergic reactions to one of the choices above. Please specify what you are allergic to and what type of reaction you have.(Required)

Please list each treatment, how long you took it, as well as any side effects you may have experienced (e.g., joint pain, swelling)

Do you have any addional health information you would like to add? Let us know if you have any of the following.(Required)

I have more information.

I'm all set, I don't have any more to add

Please add any additional information you would like your provider to know.(Required)

E.g. Any additional symptoms, medical conditions you would like us to know about, etc.

Sermorelin Agreement(Required)

I understand Sermorelin is prescribed to support my selected goals.

I confirm:
I have no active cancer or untreated endocrine tumors.
I will report side effects (joint pain, swelling, carpal tunnel).
I understand this medication may not be permitted in many organized sports.
I will follow dosing instructions.