SS-31 Mitochondrial Peptide Screening Form Template
SS-31 (Elamipretide) is a mitochondria-targeting peptide that protects cardiolipin in the inner mitochondrial membrane, improving mitochondrial function and reducing oxidative stress. It is prescribed off-label through compounding pharmacies for mitochondrial dysfunction, cardiovascular protection, cognitive fatigue, and age-related energy decline. This screening form documents energy and performance symptoms while screening for cardiovascular, neurologic, and oncologic contraindications.
Free Template
SS-31 Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
SS-31 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.
SS-31 is not FDA-approved and is prescribed off-label. Documented informed consent is required. See FSMB: https://www.fsmb.org
SS-31 is being studied in clinical trials for heart failure and mitochondrial myopathy. Providers should review current trial status and FDA guidance before prescribing. See ClinicalTrials.gov: https://clinicaltrials.gov
SS-31 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 SS-31 used for in clinical practice?
SS-31 (Elamipretide) is used off-label for mitochondrial dysfunction, cardiovascular protection, cognitive fatigue, and age-related energy decline. It works by protecting cardiolipin in the inner mitochondrial membrane, improving cellular energy production.
Is SS-31 being studied in clinical trials?
Yes. SS-31 is under active investigation in clinical trials for conditions including heart failure with preserved ejection fraction (HFpEF) and primary mitochondrial myopathy. Providers should review current trial status and publications.
What are the main contraindications for SS-31?
Known hypersensitivity to the peptide, active malignancy, and severe cardiovascular instability are the primary contraindications. Providers should evaluate each patient's full cardiovascular history before initiating therapy.