Kisspeptin Peptide Screening Form Template
Kisspeptin is a naturally occurring neuropeptide that plays a central role in regulating the hypothalamic-pituitary-gonadal (HPG) axis. It stimulates GnRH release, driving LH and FSH secretion to support reproductive hormone function. It is prescribed off-label through compounding pharmacies for patients with reduced libido, fertility concerns, and symptoms of hormonal dysregulation. This screening form helps providers document reproductive health symptoms and evaluate contraindications before initiating kisspeptin therapy.
Free Template
Kisspeptin Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Kisspeptin 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.
Kisspeptin is not FDA-approved for clinical use and must be prescribed off-label with documented informed consent. See FSMB: https://www.fsmb.org
Kisspeptin use during pregnancy or active fertility monitoring requires specialist coordination. Providers should consult reproductive endocrinology guidance when treating fertility patients.
Hormone-sensitive cancers (e.g., estrogen-receptor positive breast cancer, prostate cancer) are contraindications. Obtain oncology clearance if applicable.
Kisspeptin 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 Kisspeptin used for in clinical practice?
Kisspeptin is used off-label to support the HPG axis in patients with reduced libido, hypogonadotropic hypogonadism, fertility concerns, and hormonal dysregulation. It is being studied as a fertility trigger in assisted reproduction as well.
Can Kisspeptin be used alongside TRT or HRT?
In some protocols, Kisspeptin is used with or in place of traditional hormone therapies. Provider coordination is important to avoid over-stimulation of the HPG axis when combining with exogenous hormones.