LL-37 Antimicrobial Peptide Screening Form Template
LL-37 is a human cathelicidin antimicrobial peptide with immunomodulatory, wound healing, and anti-inflammatory properties. It is prescribed off-label through compounding pharmacies for patients with recurrent infections, slow-healing wounds, and immune dysfunction. LL-37 has both pro- and anti-inflammatory effects depending on context, making careful patient screening essential. This form documents immune-related symptoms and screens for contraindications including autoimmune disease and immunosuppressive therapy.
Free Template
LL-37 Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
LL-37 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.
LL-37 is not FDA-approved and is prescribed off-label. Documented informed consent is required. See FSMB: https://www.fsmb.org
LL-37 has immunomodulatory properties that may interact with biologic medications or immunosuppressants. Review all current medications before prescribing.
Patients with autoimmune disease require careful evaluation due to LL-37's complex immune effects. Consult rheumatology or immunology guidance as appropriate.
LL-37 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
How does LL-37 support immune function?
LL-37 is a cathelicidin peptide with broad antimicrobial activity against bacteria, viruses, and fungi. It also modulates inflammatory responses and supports wound healing by promoting tissue remodeling and angiogenesis.
Why is autoimmune disease a concern with LL-37?
LL-37 has been identified in elevated levels in certain autoimmune conditions (e.g., lupus, psoriasis). Its immunomodulatory effects could potentially exacerbate or alter autoimmune disease activity.