Methylene Blue Intake Form Template
Methylene Blue is a phenothiazine compound with mitochondrial-targeting and monoamine oxidase inhibitory properties. It is prescribed off-label through compounding pharmacies for cognitive enhancement, mitochondrial dysfunction, chronic fatigue, and mood support. Due to its MAO inhibitory activity, Methylene Blue carries a serious risk of serotonin syndrome when combined with serotonergic medications. Thorough medication screening is critical before prescribing.
Free Template
Methylene Blue Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Methylene Blue Intake Form
1 General Patient Information
Please provide your personal information.
General Patient Information
Please provide your personal information.
First Name
Jane
Last Name
Smith
Date of Birth
—
Can you confirm you are 18 years or older?
Height
e.g. 5'8"
Weight
e.g. 170 lbs
2 Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Are you actively taking any medications? If so, please list them.
List all current medications, dosages, and frequencies
Do you have any medication allergies? If so, please list them.
List all known drug allergies and reactions
Are you currently being treated or have you been treated for any medical conditions? If so, please list them.
List all current and past medical conditions
Have you had any past surgeries? If so, please list them.
List all surgeries and approximate dates
What is/was your sex assigned at birth?
Male
Emergency contact name and phone number
Name — (555) 000-0000
Mailing address
123 Main St, City, State, ZIP
Any other questions or concerns?
Optional — share anything else you'd like your provider to know
3 Symptoms
Select all symptoms that currently apply to you.
Symptoms
Select all symptoms that currently apply to you.
4 Contraindications
Please read each item carefully and select all that apply.
Contraindications
Please read each item carefully and select all that apply.
5 Additional Screening Questions
These questions are required for safe Methylene Blue prescribing.
Additional Screening Questions
These questions are required for safe Methylene Blue prescribing.
Do you have a known deficiency of G6PD (glucose-6-phosphate dehydrogenase)?
Do you understand that you should not consume alcohol while taking Methylene Blue, as it may increase the risk of liver damage and affect how your body metabolizes ethanol?
Preview only. Your live form will include your branding and e-signature capture.
Compliance & Regulatory Notes
Review these notes before deploying this form in your practice.
Methylene Blue has MAO inhibitory activity and carries an FDA boxed warning for serotonin toxicity when combined with serotonergic agents. This is a critical drug interaction that must be screened before every prescription. See FDA Drug Safety Communication: https://www.fda.gov/drugs/drug-safety-and-availability
G6PD deficiency is a contraindication. Methylene Blue relies on G6PD for its reduction and can cause hemolytic anemia in G6PD-deficient patients.
Methylene Blue for clinical use must be compounded or sourced as a pharmaceutical-grade product. Avoid research-grade sources. See FDA: https://www.fda.gov/drugs/human-drug-compounding
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Sources & References
Frequently Asked Questions
Why is serotonin syndrome a concern with Methylene Blue?
Methylene Blue inhibits monoamine oxidase (MAO), which metabolizes serotonin. When combined with SSRIs, SNRIs, MAOIs, or other serotonergic drugs, this can cause dangerous serotonin accumulation leading to serotonin syndrome, a potentially life-threatening condition.
What is G6PD deficiency and why does it matter?
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a genetic condition affecting red blood cell antioxidant defense. Methylene Blue requires G6PD activity to function as an antioxidant and can cause hemolytic anemia in G6PD-deficient patients.