Optimum Standard Group

Women's Comprehensive Biomarker & Health Intake

Confidential — Peptide, Longevity & Nutritional Science Advisory Panel
Section 1 of 8

Personal Information

Basic demographics and provider details. Race/ethnicity is clinically relevant — biomarker reference ranges and hormonal timelines vary significantly by background.

Biomarker reference ranges, disease risk, and hormonal timelines vary by race/ethnicity (SWAN study data).
Body Composition
Healthcare Providers
Section 2 of 8

Reproductive & Hormonal Health

Menstrual, pregnancy, and hormonal history. This drives peptide and fasting protocol design.

Menstrual Status
Pregnancy & Fertility
Hormonal History
Menopausal Symptoms (if applicable)
Rate severity: 0 = None, 1 = Mild, 2 = Moderate, 3 = Severe
SymptomSeverityNotes
Section 3 of 8

Medical History

Current diagnoses, surgical history, and family medical history.

Current Diagnoses
Surgical History
Family History
Indicate family member and age of onset if known.
Section 4 of 8

Medications, Supplements & Peptides

Everything you're currently taking — prescription, supplement, and peptide.

Prescription Medications
MedicationDoseFrequencyDuration
Current Supplements
SupplementDoseFrequencyReason
Peptide History
Section 5 of 8

Biomarker Panel

Most recent lab results. Leave blank if not tested — the think tank may recommend it. Attach full reports if available.

Metabolic Panel
MarkerValueUnits
Hormonal Panel — Female
Ideal timing: Day 3 for FSH/LH/Estradiol, Day 19-21 for Progesterone.
MarkerValueUnits
Thyroid Panel
MarkerValueUnits
Inflammatory & Nutrient Markers
MarkerValueUnits
Section 6 of 8

Biomarkers (continued)

Growth hormone, longevity markers, CBC, bone health, and gut health.

Growth Hormone & Longevity
MarkerValueUnits
Complete Blood Count
MarkerValueUnits
Bone Health
MarkerValueUnits
Gut Health
TestResultProvider/Date
Section 7 of 8

Lifestyle, Nutrition & Movement

Diet, fasting, exercise, sleep, and stress profile.

Nutrition
Fasting
Exercise
Sleep
Stress & Mental Health
Racial stress and discrimination are documented contributors to allostatic load, chronic inflammation, and accelerated biological aging. This data is clinically relevant.
Section 8 of 8

Goals & Consent

Your priorities, what optimal health looks like for you, and acknowledgment.

Your Goals
Acknowledgment & Consent

I understand that the Optimum Standard Group Advisory Think Tank provides educational guidance and biomarker-informed recommendations. This is NOT a substitute for medical care from a licensed physician. I will review any recommendations with my personal healthcare provider before implementation.


I understand my biomarker data and health information will be reviewed by Advisory Think Tank members solely for providing personalized recommendations. My information will be kept confidential.


I certify the information provided is accurate and complete to the best of my knowledge.

Intake Form Submitted

Your comprehensive biomarker and health intake has been received. The Advisory Think Tank will review your submission and you'll receive your personalized recommendations within the timeframe specified by your consultation tier.

Submitting your intake form...