Pinealon / PE22-28 / Selank Peptide Screening Form Template
Pinealon, PE22-28, and Selank are neuropeptides with complementary anxiolytic, cognitive-enhancing, and sleep-regulatory effects. Pinealon supports pineal gland function and neuroprotection; PE22-28 is a synthetic peptide with antidepressant and cognitive-enhancement properties; Selank is an anxiolytic peptide that modulates GABAergic and serotonergic activity. This combination screening form helps providers evaluate patients with anxiety, cognitive concerns, and sleep disturbances while documenting neuropsychiatric contraindications.
Free Template
Pinealon / PE22-28 / Selank Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Pinealon / PE22-28 / Selank 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.
All three peptides are prescribed off-label. Informed consent should list each compound individually. See FSMB: https://www.fsmb.org
Patients on psychiatric medications (antidepressants, anxiolytics, antipsychotics) require careful evaluation for drug interactions before initiating neuropeptide therapy.
These peptides 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 Selank differ from traditional anti-anxiety medications?
Selank is a synthetic heptapeptide analogue of tuftsin with anxiolytic properties that does not cause sedation, dependence, or withdrawal effects associated with benzodiazepines. It modulates GABAergic and serotonergic systems through a distinct mechanism.
Can these peptides be used alongside psychiatric medications?
Concurrent use with antidepressants, anxiolytics, or other CNS-active medications requires careful provider evaluation. Potential additive effects and drug interactions must be reviewed on a case-by-case basis.