Epithalon Peptide Screening Form Template
Epithalon (Epitalon) is a synthetic tetrapeptide derived from the pineal gland polypeptide Epithalamin. It is studied for its effects on telomere elongation, pineal gland regulation, sleep quality, and anti-aging properties. Prescribed off-label through compounding pharmacies, Epithalon is used in longevity medicine, integrative oncology recovery, and sleep support protocols. This screening form helps providers assess symptom burden, identify contraindications, and document eligibility before initiating therapy.
Free Template
Epithalon Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Epithalon 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.
Epithalon is not FDA-approved and must be prescribed off-label with documented informed consent. See FSMB: https://www.fsmb.org
As a longevity-focused peptide, Epithalon is often used in patients with complex health histories. Thorough medical history review is recommended before initiating therapy.
Epithalon must be dispensed through a licensed compounding pharmacy. See FDA compounding guidance: https://www.fda.gov/drugs/human-drug-compounding
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Sources & References
Frequently Asked Questions
What is Epithalon used for in anti-aging medicine?
Epithalon is studied for its role in activating telomerase, which may support telomere maintenance and cellular longevity. It is also used for sleep regulation via pineal gland modulation. All uses are off-label.
Is Epithalon safe for patients with a cancer history?
A history of malignancy is a contraindication that must be carefully evaluated. Providers should consult current oncology guidance and obtain specialist clearance before prescribing to patients with cancer history.