CJC-1295 / Ipamorelin Peptide Screening Form Template
CJC-1295 and Ipamorelin are growth hormone-releasing peptides (GHRPs) that stimulate the pituitary gland to produce more growth hormone. They are prescribed off-label for body composition, recovery, sleep quality, and anti-aging indications. This screening form helps providers identify appropriate candidates while documenting contraindications including metabolic conditions, pituitary disorders, and hormone-sensitive conditions prior to initiating a growth hormone secretagogue protocol.
Free Template
CJC-1295 / Ipamorelin Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
CJC-1295 / Ipamorelin 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.
CJC-1295 and Ipamorelin are growth hormone secretagogues prescribed off-label. Informed consent documenting the off-label nature is required. See FSMB: https://www.fsmb.org
Growth hormone secretagogues may affect insulin sensitivity and blood glucose. Patients with diabetes or metabolic disorders require closer monitoring.
These peptides must be dispensed by a licensed compounding pharmacy. Verify 503A/503B status. See FDA: https://www.fda.gov/drugs/human-drug-compounding
Want This Form Automated?
Karpa Health turns static intake forms into a fully automated clinical workflow. Branded, HIPAA-compliant, and connected to compounding pharmacies.
- Branded intake on your website
- AI contraindication screening
- One-click prescribing to pharmacies
- Automated refill management
- E-signatures and HIPAA audit trail
- 50-state provider network included
Free 30-minute walkthrough
Sources & References
Frequently Asked Questions
What is the difference between CJC-1295 and Ipamorelin?
CJC-1295 is a GHRH analog that stimulates sustained growth hormone release, while Ipamorelin is a GHRP that mimics ghrelin to trigger pulsatile GH release. They are often combined for synergistic effect on growth hormone secretion.
Why is diabetes a contraindication for growth hormone secretagogues?
Growth hormone can increase insulin resistance and elevate blood glucose. Patients with diabetes or impaired glucose tolerance require careful monitoring and may not be appropriate candidates without additional evaluation.