Thymosin Alpha-1 Peptide Screening Form Template
Thymosin Alpha-1 (Ta1) is a thymic peptide that regulates and enhances immune function by stimulating T-cell maturation, natural killer cell activity, and dendritic cell function. It is prescribed off-label through compounding pharmacies for immune support, chronic infection recovery, and immune modulation in integrative medicine. This screening form documents immune-related symptoms and screens for autoimmune conditions, malignancy, and immunosuppressive therapy use before initiating Ta1 therapy.
Free Template
Thymosin Alpha-1 Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Thymosin Alpha-1 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.
Thymosin Alpha-1 is not FDA-approved for general immune support and is prescribed off-label. Documented informed consent is required. See FSMB: https://www.fsmb.org
Ta1 is FDA-approved as Zadaxin in some countries. US providers should verify current FDA compounding and approval status before prescribing.
Patients with autoimmune disease may be at risk of immune flares with Ta1. Consult rheumatology or immunology guidance as appropriate.
Ta1 must be dispensed by a licensed compounding pharmacy. See FDA: https://www.fda.gov/drugs/human-drug-compounding
Want This Form Automated?
Karpa Health turns static intake forms into a fully automated clinical workflow. Branded, HIPAA-compliant, and connected to compounding pharmacies.
- Branded intake on your website
- AI contraindication screening
- One-click prescribing to pharmacies
- Automated refill management
- E-signatures and HIPAA audit trail
- 50-state provider network included
Free 30-minute walkthrough
Sources & References
Frequently Asked Questions
What conditions benefit most from Thymosin Alpha-1?
Ta1 is used for immune enhancement in patients with chronic or recurrent infections, post-viral fatigue, and impaired immune recovery. It has been studied extensively for hepatitis B/C, cancer immunotherapy support, and general immune modulation.
Is Thymosin Alpha-1 safe for autoimmune patients?
Autoimmune disease is a relative contraindication. While Ta1 has been used in some autoimmune contexts, its immune-stimulating properties could potentially worsen autoimmune activity. Specialist evaluation is recommended.