Welcome

Your health,
understood completely.

This questionnaire forms the foundation of your Signa Peptide protocol. Every question matters — your answers determine which peptides are appropriate, which are contraindicated, and what your bloodwork needs to show before we begin.

Consultation fee

€120 — one-time, covers this intake and your practitioner review

Ongoing protocol membership is separate and shown once your consultation has been reviewed. Nothing further is charged today beyond this consultation fee.

Before you start — please read

This is a coaching and education consultation, not a medical consultation. All protocols produced from this questionnaire should be reviewed with your physician before implementation.

The questionnaire takes approximately 10–12 minutes to complete. Answer honestly — particularly regarding medical history. Information that seems minor to you can be clinically significant for protocol design.

A blood test is required before we can build your protocol. If you do not yet have one, this questionnaire will tell you exactly what to ask your doctor for. You can complete the form without it and upload results later.

What happens next

Once submitted, your questionnaire is reviewed by our practitioner team. You will receive your personalised consultation report within 5 working days of your completed blood panel being received. The report will contain your full protocol, phased timeline, dosing instructions, and monitoring schedule.

I understand this is a coaching and education intake, not a medical prescription. I understand my answers and bloodwork will be reviewed by a practitioner before any protocol is dispensed. I understand the consultation fee of €120 covers this intake and practitioner review.

Section 1 of 7

Personal
details

Basic information used to contextualise your results and protocol recommendations.

First name

Last name

Date of birth

Biological sex

Country of residence

City

Height (cm)

Weight (kg)

BMI

Email address

1 / 7

Section 2 of 7

Your goals &
priorities

Select everything that applies. There are no wrong answers — this helps us understand what outcomes matter most to you.

Primary goals

What is your single most important goal?

If you had to choose one thing this protocol must achieve, what would it be?

Timeline

How long are you prepared to commit to a structured protocol?

2 / 7

Section 3 of 7

Medical
history

This section determines which peptides are safe for your specific profile. Please answer honestly — some conditions are absolute contraindications for certain agents.

Why this matters: Several peptides carry meaningful risk in individuals with specific conditions. GH-axis peptides require cancer risk assessment. Angiogenic peptides require thyroid nodule screening. This is not a formality — your answers directly shape what is and is not included in your protocol.

Cancer & growth risk

Personal history of cancer

No Yes Unsure

Please specify type and current status

Family history of cancer (first-degree relatives)

Parents, siblings, or children

No Yes Unsure

Please specify (type and relation)

Cardiovascular & metabolic

Do you have or have you had any of the following? Select all that apply.

Atrial fibrillation (AFib) High blood pressure (hypertension) Heart attack or stroke Blood clots / DVT / PE Type 1 or Type 2 diabetes Insulin resistance / metabolic syndrome High cholesterol or dyslipidaemia None of the above

Thyroid, hormonal & autoimmune

Thyroid conditions

Hypothyroidism (underactive thyroid) Hyperthyroidism (overactive thyroid) Thyroid nodules (benign or uncharacterised) Hashimoto's thyroiditis Graves' disease None

Autoimmune conditions

Other medical history

Liver or kidney conditions

Liver disease (fatty liver, hepatitis, cirrhosis) Chronic kidney disease or renal impairment None

Psychiatric conditions

Relevant for neuroactive peptides (Selank, Semax, Cerebrolysin). These peptides require cautious use in psychiatric instability.

Recent surgeries or injuries

Relevant for tissue repair peptides (BPC-157, TB-500, GHK-Cu)

Any other diagnosed conditions not listed above

3 / 7

Section 4 of 7

Medications &
supplements

Drug and supplement interactions must be assessed before any peptide protocol is designed. Include everything, including over-the-counter medications.

Are you currently taking any prescription medications?

No Yes

List all current medications, doses, and frequency

Are you currently taking any blood thinners or anticoagulants?

Including aspirin, warfarin, rivaroxaban, apixaban, clopidogrel, or fish oil at high doses

No Yes

Specify medication and dose

Current supplements

List vitamins, minerals, protein supplements, pre-workouts, herbal supplements, etc.

Have you used peptides before?

Never Yes — with guidance Yes — self-directed

Which peptides have you used, at what doses, and what was your experience?

Are you comfortable with subcutaneous (under-skin) self-injection?

Yes, comfortable Willing to learn No — prefer non-injectable options

Known allergies

4 / 7

Section 5 of 7

Lifestyle &
current health

Peptides amplify the response to training, nutrition, and recovery — they do not replace them. Understanding your current baseline helps us calibrate what is realistically achievable.

Training & activity

Training frequency

Sedentary 1–2× / week 3–4× / week 5+ × / week

Nutrition

Sleep, stress & recovery

Alcohol consumption

None Occasional Moderate (1–3 units/day) Heavy (>3 units/day)

Smoking / nicotine

Never Ex-smoker Current smoker Nicotine replacement

5 / 7

Section 6 of 7

Your blood
test

A blood panel is the foundation of a safe and effective peptide protocol. Below you will find exactly what to request from your doctor — and why each marker matters.

Blood test required before protocol design. If you do not yet have results, complete this questionnaire and upload your blood test separately when available. We cannot design a full protocol without a minimum of the Core Panel below.

Optimal Blood Panel for Peptide Protocol Design

Request this panel from your GP, endocrinologist, or private lab. Fasting required for at least 10–12 hours before the draw.

Metabolic & glucose — everyone

Fasting glucose Fasting insulin HbA1c HOMA-IR (calculated) Total cholesterol HDL cholesterol LDL cholesterol Triglycerides ApoB (preferred over LDL) Lipoprotein(a)

Liver, kidney & organ function — everyone

AST (liver) ALT (liver) GGT Alkaline phosphatase Bilirubin (total) Creatinine eGFR / GFR Urea Uric acid

Thyroid — everyone

TSH Free T3 Free T4 Anti-TPO Anti-TG (Anti-thyroglobulin)

Inflammation & cardiovascular risk — everyone

hs-CRP (high-sensitivity) Homocysteine Fibrinogen

Haematology — everyone

Full blood count (FBC/CBC) Haematocrit Haemoglobin MPV (mean platelet volume)

Vitamins, minerals & micronutrients — everyone

Vitamin D (25-OH) Folic acid / Folate Vitamin B12 (active or serum) Ferritin Serum iron Transferrin / TIBC Magnesium (serum) Zinc

GH axis — required before GH peptides

IGF-1 IGFBP-3 GH (fasting)

Hormonal — males

Total testosterone Free testosterone SHBG Estradiol (E2) DHEA-S Cortisol (AM, fasting) LH / FSH PSA (40+)

Hormonal — females

Estradiol (E2) Progesterone Total & free testosterone SHBG FSH LH DHEA-S Cortisol (AM, fasting) Prolactin AMH (if applicable)

Core — required for all clients

Males

Females

Do you have blood test results to submit?

Yes — upload now Yes — will send separately No — not yet done

↑

Click to upload or drag and drop
PDF, JPG, or PNG — multiple files accepted

Blood test date

Laboratory name (if known)

When was / will the blood test be taken?

No blood test yet. No problem — submit this questionnaire and arrange your blood draw using the panel above. Your protocol design begins once results are received. We recommend using a private lab if your GP does not cover the full panel. Typical turnaround is 3–5 working days.

Are there any results from previous blood tests you'd like to share?

Even older results can provide useful context for protocol design

Yes No

↑

Upload previous blood tests

6 / 7

Section 7 of 7

Review &
submit

Almost done. Add any final information, confirm your details, and submit.

Is there anything else you want us to know before designing your protocol?

Context that did not fit elsewhere — previous protocol experiences, specific concerns, lifestyle constraints, etc.

How did you hear about Signa Peptide?

Declarations

I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand this is a coaching and education consultation, not medical care, and all recommendations should be reviewed with my physician before implementation. I understand that peptides are for research purposes only and Signa Peptide makes no medical claims. I consent to my information being stored securely and used for the purpose of creating my personalised protocol.

By submitting this questionnaire you confirm the above declarations. Signa Peptide reserves the right to decline a consultation or request additional information before proceeding. Your data is held in strict confidence and is never shared with third parties.

✓

Submitted

Questionnaire received.
We'll be in touch.

Thank you for completing your Signa Peptide health screening. Your questionnaire has been submitted and is being reviewed by our team.

Practitioner review status

Checking...

Send your report to your practitioner directly

Whether or not automatic saving worked above, you can also send your answers yourself right now — two steps:

Downloads a plain-text summary of every answer you gave, then opens an email to protocols@signapeptide.com — attach the downloaded file before sending.

What happens next

If you have uploaded blood results: You will receive your consultation report within 5 working days.

If your blood test is pending: Submit your results to protocols@signapeptide.com and your protocol will be designed within 5 working days of receipt.

If you have any questions in the meantime, contact us directly at the same address.

Your health,understood completely.

Personaldetails

Your goals &priorities

Medicalhistory

Medications &supplements

Lifestyle &current health

Your bloodtest

Review &submit

Questionnaire received.We'll be in touch.

Your health,
understood completely.

Personal
details

Your goals &
priorities

Medical
history

Medications &
supplements

Lifestyle &
current health

Your blood
test

Review &
submit

Questionnaire received.
We'll be in touch.