BPC-157 Peptide Screening Form Template
BPC-157 (Body Protection Compound-157) is a synthetic pentadecapeptide studied for its tissue repair, anti-inflammatory, and cytoprotective properties. It is prescribed off-label and compounded by licensed pharmacies for indications including joint and tendon recovery, chronic inflammation, and soft tissue healing. This screening form helps providers identify patients who may benefit from BPC-157 therapy while documenting contraindications and relevant medical history before initiating treatment.
Free Template
BPC-157 Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
BPC-157 Peptide Screening 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 Medical Conditions
Select all conditions that currently apply to you.
Medical Conditions
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.
BPC-157 is not FDA-approved and is prescribed off-label. Off-label prescribing requires documented informed consent per FSMB guidance. See FSMB: https://www.fsmb.org
BPC-157 must be dispensed through a licensed 503A or 503B compounding pharmacy. Verify current FDA compounding status before prescribing. See FDA compounding guidance: https://www.fda.gov/drugs/human-drug-compounding
Some formulations of BPC-157 have faced FDA regulatory scrutiny. Practices should monitor FDA.gov for current guidance and update prescribing protocols accordingly.
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Sources & References
Frequently Asked Questions
Who is a candidate for BPC-157 therapy?
Patients with musculoskeletal injuries, chronic tendon or ligament issues, or inflammatory soft tissue conditions may be candidates. A provider must evaluate each patient's full medical history and contraindications before prescribing.
Is BPC-157 FDA-approved?
No. BPC-157 is prescribed off-label and must be compounded by a licensed pharmacy. Patients must provide informed consent acknowledging the off-label and investigational nature of the treatment.
What are the main contraindications for BPC-157?
Active or prior malignancy, autoimmune conditions, use of immunosuppressants or anticoagulants, and known hypersensitivity to peptide therapies are the primary contraindications providers should screen for.