Semax / Selank Cognitive Peptide Screening Form Template
Semax and Selank are synthetic neuropeptides developed for cognitive enhancement and anxiolytic effects. Semax is an ACTH-derived peptide that increases BDNF levels and improves focus, memory, and mental clarity. Selank is a tuftsin-derived peptide with anxiolytic properties that reduces stress without sedation or dependence. Together they are used in clinical protocols targeting cognitive performance, anxiety, and mental fatigue. This screening form documents cognitive and emotional symptoms while evaluating neuropsychiatric contraindications.
Free Template
Semax / Selank Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Semax / 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.
Semax and Selank are prescribed off-label. Informed consent should document the investigational nature of both compounds. See FSMB: https://www.fsmb.org
Semax increases BDNF and may interact with stimulant or ADHD medications. Providers should review all current CNS medications before prescribing.
Seizure disorders require careful evaluation before initiating Semax, which has neurotrophin-stimulating effects.
All 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
What is Semax used for in clinical practice?
Semax is an ACTH(4-7) analogue that stimulates BDNF production and improves attention, memory, and cognitive performance. It is used off-label for cognitive enhancement, focus, and neuroprotection.
Are Semax and Selank habit-forming?
Neither Semax nor Selank has demonstrated dependence or withdrawal effects in clinical research. Selank in particular is noted for its favorable safety profile compared to benzodiazepines and other anxiolytics.