MOTS-c Mitochondrial Peptide Screening Form Template
MOTS-c (Mitochondrial Open Reading Frame of the 12S rRNA-c) is a mitochondria-derived peptide that regulates metabolic homeostasis, insulin sensitivity, and exercise endurance. It is prescribed off-label through compounding pharmacies for metabolic dysfunction, weight management, and physical performance optimization. This screening form documents metabolic symptoms and screens for conditions including insulin resistance, malignancy, and mitochondrial disorders before initiating MOTS-c therapy.
Free Template
MOTS-c Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
MOTS-c 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.
MOTS-c is not FDA-approved and is prescribed off-label. Documented informed consent is required. See FSMB: https://www.fsmb.org
MOTS-c improves insulin sensitivity, which may affect glucose management in diabetic patients. Monitor blood glucose closely in patients on insulin or hypoglycemic agents.
MOTS-c 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 makes MOTS-c different from other metabolic peptides?
MOTS-c is unique as a mitochondria-derived peptide (mitokine) that directly regulates cellular energy metabolism and insulin signaling. Unlike growth hormone secretagogues, it does not stimulate GH and has a distinct metabolic mechanism.
Can MOTS-c be used for weight loss?
MOTS-c is studied for its role in metabolic regulation and may support weight management as part of a comprehensive metabolic health protocol. It is not a standalone weight loss treatment and works best alongside lifestyle interventions.