Tesamorelin Peptide Screening Form Template
Tesamorelin is a growth hormone-releasing hormone (GHRH) analogue approved by the FDA for HIV-associated lipodystrophy and used off-label for visceral fat reduction, body composition improvement, and metabolic health. It stimulates pituitary GH release in a physiologic, pulsatile manner. This screening form documents body composition symptoms and screens for metabolic, endocrine, and oncologic contraindications before initiating tesamorelin therapy.
Free Template
Tesamorelin Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Tesamorelin 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.
Tesamorelin is FDA-approved for HIV-associated lipodystrophy. Off-label use for body composition requires documented informed consent. See FSMB: https://www.fsmb.org
Tesamorelin may increase insulin resistance and blood glucose. Monitor HbA1c and fasting glucose in patients with metabolic disorders.
Active malignancy is a contraindication due to the mitogenic properties of growth hormone. Patients with cancer history require specialist evaluation.
Tesamorelin must be dispensed by a licensed compounding pharmacy for off-label use. See FDA: https://www.fda.gov/drugs/human-drug-compounding
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Sources & References
Frequently Asked Questions
Is Tesamorelin FDA-approved?
Tesamorelin (Egrifta) is FDA-approved for the reduction of excess abdominal fat in HIV-infected patients with lipodystrophy. Off-label use for general body composition requires additional informed consent disclosures.
How does Tesamorelin differ from direct growth hormone injections?
Tesamorelin stimulates the pituitary to release GH in a natural, pulsatile pattern, avoiding the supraphysiologic levels associated with direct GH administration. This generally results in a more favorable side effect profile.