Oxytocin Intake Form Template
Oxytocin is a neuropeptide and hormone prescribed off-label through compounding pharmacies for sexual health, stress reduction, emotional bonding, and weight management support. It is available in intranasal, sublingual, and injectable formulations. This intake form documents wellness and sexual health symptoms while screening for contraindications including cardiovascular conditions, infection, and allergy.
Free Template
Oxytocin Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Oxytocin 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
Select all conditions that currently apply to you.
Contraindications
Select all conditions that currently apply to you.
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.
Oxytocin is FDA-approved for labor induction (IV). Off-label intranasal or sublingual use requires informed consent and compounding pharmacy dispensing. See FSMB: https://www.fsmb.org
Cardiovascular conditions including hypertension and arrhythmias are contraindications due to oxytocin's vasoactive properties.
Oxytocin must be compounded by a licensed 503A or 503B pharmacy for off-label use. See FDA: https://www.fda.gov/drugs/human-drug-compounding
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Sources & References
Frequently Asked Questions
What is oxytocin used for in a wellness context?
Off-label intranasal oxytocin is used for stress reduction, emotional bonding, libido support, and appetite regulation. It is sometimes called the bonding hormone for its role in social connection and trust.
Why is oxytocin contraindicated with cardiovascular disease?
Oxytocin has vasodilatory and antidiuretic effects that can affect heart rate and blood pressure. Patients with pre-existing heart conditions or arrhythmias require additional cardiovascular evaluation.