DSIP Peptide Screening Form Template
Delta Sleep-Inducing Peptide (DSIP) is a neuropeptide studied for its role in sleep regulation, stress response, and neuroendocrine function. It is prescribed off-label through compounding pharmacies for patients with sleep disturbances, insomnia, and stress-related sleep disruption. This screening form helps providers document sleep-related symptoms, identify contraindications, and confirm patient eligibility before initiating DSIP therapy.
Free Template
DSIP Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
DSIP 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.
DSIP is not FDA-approved and is prescribed off-label. Documented informed consent is required per FSMB guidance. See FSMB: https://www.fsmb.org
Patients using sedatives, benzodiazepines, or other CNS-active medications should be evaluated for drug interactions before initiating DSIP therapy.
DSIP must be dispensed through a licensed 503A or 503B compounding pharmacy. Verify current FDA compounding status. See FDA: https://www.fda.gov/drugs/human-drug-compounding
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Sources & References
Frequently Asked Questions
What is DSIP used for in clinical practice?
DSIP is an off-label peptide therapy used for sleep support, stress-related sleep disturbances, and neuroendocrine regulation. It is typically administered subcutaneously and compounded by a licensed pharmacy.
Can DSIP interact with sleep medications?
Yes. Concurrent use of sedatives, sleep aids, or CNS-active medications may produce additive effects. A provider should review all current medications before prescribing DSIP.