DSIP / BPC-157 / CJC Combination Peptide Screening Form Template
This combination screening form is designed for patients being evaluated for a multi-peptide protocol incorporating DSIP (sleep/stress modulation), BPC-157 (tissue repair and inflammation), and CJC-1295 or Ipamorelin (growth hormone support). Combination peptide protocols require a consolidated screening approach to capture symptoms across all therapeutic targets while documenting all relevant contraindications. Use this form when a patient is being considered for two or more of these peptides simultaneously.
Free Template
DSIP / BPC-157 / CJC Combination Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
DSIP / BPC-157 / CJC Combination 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.
Each peptide in a combination protocol is prescribed off-label. A single informed consent form should list each peptide individually. See FSMB off-label guidance: https://www.fsmb.org
Patients on CNS-active medications, anticoagulants, or immunosuppressants require careful review before initiating any peptide combination.
All peptides must be dispensed by a licensed compounding pharmacy. Verify current FDA compounding status for each peptide. See FDA: https://www.fda.gov/drugs/human-drug-compounding
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Sources & References
Frequently Asked Questions
Why use a combination screening form instead of separate forms?
When a patient is being evaluated for multiple peptides in one protocol, a single consolidated screening form is more efficient and captures overlapping contraindications in one review. Separate forms may be used if peptides are initiated at different times.
Are there additional risks with peptide combinations?
Combination protocols may have additive or synergistic effects. Providers should consider all potential drug interactions and overlapping contraindications when prescribing multiple peptides simultaneously.