AgeMD™

Biological Sex

Male

Female

Prefer not to say

What would you most like to improve right now?

Energy levels

Libido / sexual health

Mood & emotional balance

Mental clarity & focus

Muscle tone / body composition

Overall well-being

Which areas have been affecting your quality of life? (Select all that apply)

Fatigue or low energy

Reduced libido or interest

Mood changes or irritability

Brain fog

Weight gain or difficulty losing fat

Poor sleep

Reduced motivation

None of the above

AgeMD™

How long have you been noticing these changes?

Less than 3 months

3–6 months

6–12 months

Over a year

Not sure

Do these symptoms tend to be:

Consistent most days

On and off

Gradually worsening

Hard to tell

AgeMD™

How would you describe your activity level?

Mostly sedentary

Light activity (walking, light workouts)

Moderate exercise 2–3x/week

Very active

How is your sleep most nights?

Restful and consistent

Fair

Poor or inconsistent

Not sure

How would you rate your stress levels lately?

Low

Moderate

High

Varies significantly

AgeMD™

Have you ever had your hormone levels tested?

Yes

Not sure

Have you ever used hormone-related or peptide therapies before?

Yes

Not sure

AgeMD™

Have you ever been diagnosed with any of the following?

Heart disease or stroke

Hormone-sensitive cancer (e.g., prostate, breast)

Blood clots

Sleep apnea

Thyroid disorders

High cholesterol

None of the above

Are you currently taking any prescription medications?

Yes

Please give us a brief of the medications currently prescribed to you

AgeMD™

What best describes your approach to results?

Long-term hormone optimization

Symptom relief and balance

I’m exploring options right now

How open are you to regular monitoring and follow-ups if recommended?

Very open

Somewhat open

Not sure yet

Full Name

Date of birth

Phone *

Email *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.