IGF-LR3 Peptide Screening Form Template
IGF-LR3 (Insulin-like Growth Factor-1 Long R3) is a potent growth factor peptide that enhances the effects of growth hormone on muscle protein synthesis, cellular repair, and metabolic function. It is prescribed off-label through compounding pharmacies for body composition, recovery optimization, and anabolic support. Due to its insulin-like effects, careful metabolic screening is essential before initiating therapy. This form documents symptom burden and contraindications for safe patient selection.
Free Template
IGF-LR3 Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
IGF-LR3 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.
IGF-LR3 is not FDA-approved and is prescribed off-label. Informed consent documenting the investigational nature of the therapy is required. See FSMB: https://www.fsmb.org
IGF-LR3 has potent insulin-like hypoglycemic effects. Patients must be counseled on hypoglycemia risk and monitoring protocols.
Due to IGF-1's mitogenic properties, patients with any history of malignancy should be carefully evaluated. Active cancer is a contraindication.
IGF-LR3 must be dispensed by a licensed compounding pharmacy. See FDA: https://www.fda.gov/drugs/human-drug-compounding
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Sources & References
Frequently Asked Questions
What is the difference between IGF-LR3 and standard IGF-1?
IGF-LR3 is a modified analogue of IGF-1 with a longer half-life and greater potency. It has reduced binding to IGF-binding proteins, resulting in stronger and more prolonged activity.
Why is cancer history a contraindication for IGF-LR3?
IGF-1 and its analogues can stimulate cell proliferation through mitogenic pathways. Active malignancy or a significant history of cancer is a contraindication due to the theoretical risk of promoting tumor growth.