Zaki Anwar, MD

call or text 815-464-7212

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Peptides

Physician-Guided Peptide Therapy for

Longevity, Recovery, & Performance

Our personalized peptide therapy plans are developed by experienced MDs to support your body’s natural ability to repair, recover, and function at a higher level. Our regenerative approach focuses on optimizing health from within to improve energy, resilience, and overall wellness.

When you are ready, a member of our team will guide you through options and your next steps. We will coordinate everything for you, from ordering your peptides to ensuring you feel confident with your instructions before getting started.

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Peptide Therapy Assessment

We recommend speaking with us before completing your Peptide Assessment

First name*

Last name*

Cell Phone*

Email*

Date of birth*

Month

Day

Year

Age*

Height *

Weight*

Gender *

Male

Female

I Prefer to Specify

Are you currently a patient of

Dr. Zaki Anwar

Dr. Ayesha Akbar

Dr. Khaja Asadullah

None of these

I. PRIMARY GOALS

Please review the following goals. Rate your top priority by selecting 1, next priority as 2, and so on. Select up to 5, and leave the remaining options blank.

Recovery (exercise or injury)

Muscle gain / performance

Energy / fatigue

Sleep optimization

Cognitive function / brain fog

Hormone balance

Fat loss / body composition

Libido / sexual health

Anti-aging / longevity

Immune support

Hair, skin, nails

What results are you hoping to achieve in the next 3–6 months?

II. SYMPTOM ASSESSMENT

Please review the following symptoms, and give each one a rating.

0= not a problem, 5= significant problem

Energy & Metabolism

Fatigue*

Difficulty losing weight *

Sugar cravings *

Midday crashes *

Hormonal

Low libido *

Mood swings *

Hot flashes / night sweats (if applicable)

Erectile dysfunction (if applicable)

Cognitive

Brain fog*

Poor focus*

Memory issues*

Sleep

Trouble falling asleep *

Staying asleep *

Waking unrefreshed*

Physical

Joint pain*

Exercise intolerance *

Muscle soreness/slow recovery*

III. MEDICAL HISTORY & CONTRAINDICATIONS

Pregnant or breastfeeding?*

Yes

Any active infections or taking antibiotics? *

Yes

Allergies (especially medications/compounds) *

Yes

History of blood clots*

Yes

Have you been diagnosed with any of the following conditions?

Thyroid disorder *

Yes

Diabetes / insulin resistance *

Yes

Thyroid disorder *

Yes

Autoimmune condition *

Yes

Cardiovascular disease *

Yes

Cancer (current or history) *

Yes

Neurological condition *

Yes

Do you have any other medical conditions?*

Yes

IV. MEDICATIONS & SUPPLEMENTS

Are you taking ANY medications, including prescription or over the counter?*

Yes

Are you taking ANY medications, including prescription or over the counter?*

Yes

Are you currently on any hormone therapy?*

Yes

Have you previously used any peptides? *

Yes

V. LIFESTYLE FACTORS

Nutrition: Select your typical diet (choose all that apply)*

High protein

Low carb

Balanced

Inconsistent

Needs improvement

Other

Daily water intake*

Exercise: How often or how much do you exercise per week?*

Type of exercise (choose all that apply)*

Strength

Cardio

None

Other

Sleep: How many hours of sleep do you get on an average night?*

How well do you sleep? (0= very well, 5= very poorly)*

Stress: How do you rate your current average level of stress?*

Low

Moderate

High

Please specify your major source(s) of stress*

VI. LABS & BIOMARKERS

Have you had any bloodwork done in the last 6 months? *

Yes

To the best of your ability, please share results or list values if known. You may also list "high, low, or within normal range" if known.

Testosterone (total/ free)

Estradiol

Thyroid (TSH, T3, T4)

A1C / fasting glucose

Lipid panel

Please list any other lab results that have fallen above or below normal range.

VII. COMMITMENT & EXPECTATIONS

Are you willing to self-administer injections if recommended?*

Yes

Unsure

Do you have a preferred route of administration?*

Injection

Oral

Nasal spray

Open to best recommendation

Are you able to commit to an 8–12 week protocol, knowing that most recommendations will require refrigeration? *

Yes

Unsure

Please list anything else you want us to know about your health, goals, or concerns:

VIII. CONSENT FOR MEDICAL REVIEW & RECOMMENDATION

I certify that the information provided in this form is accurate and complete to the best of my knowledge. I understand that this information will be reviewed by a medical provider for the purpose of developing personalized wellness and/or peptide therapy recommendations.

I acknowledge that submission of this form does not establish a doctor-patient relationship, does not guarantee treatment, and does not replace a comprehensive medical evaluation when indicated.

I understand that I may be contacted if additional information is needed prior to making a recommendation.

By signing below, I consent to the review of my health information for this purpose.

Signature*

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Once your submit the Peptide Assessment form, one of our team members will reach out to you as soon as possible to discuss your next steps.

Chicago Stem Cell Therapy &

Pain Management Institute

Zaki Anwar, MD

10181 W Lincoln Hwy

Frankfort, IL 60423

New Patients Call: 815-412-6192

Main Office Call or Text: 815-464-7212

Text STEM to 815-464-7212 to learn more

OFFICE HOURS

Monday-Thursday: 9am to 5pm

Friday: 9am to 3pm

Saturday-Sunday: Closed

Link Hub

Patient Portal

This website, www.chicagostemcelltherapy.com, offers the opportunity to connect with regenerative medicine and stem cell therapy professionals as part of clinical practice. Because stem cell therapy is not the standard of care in the United States, the following important disclosures are made:

The science of treatment with stem cell therapies can be considered experimental.

The outcome of stem cell therapies will vary between patients and no particular measurement of success can be guaranteed.

There could be unknown risks associated with stem cell therapies as long-term studies have not been performed.

Treatments by licensed providers will only be performed after the patient understands and agrees to informed consent.

The testimonies of people who appear on this website have voiced their experiences at their own free will.

The stem cell therapies performed in this office are not a clinical trial.