Sermorelin Intake Form Template
Sermorelin is a synthetic analogue of growth hormone-releasing hormone (GHRH) that stimulates the pituitary gland to produce and secrete growth hormone. It is prescribed off-label through compounding pharmacies for age-related growth hormone decline, fatigue, muscle loss, sleep quality, and body composition. This intake form documents growth hormone-related symptoms and screens for contraindications including cancer history, corticosteroid use, and pregnancy.
Free Template
Sermorelin Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Sermorelin Intake 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 Contraindications
Select all conditions that currently apply to you.
Contraindications
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.
Sermorelin is not FDA-approved for general anti-aging use and is prescribed off-label. Documented informed consent is required. See FSMB: https://www.fsmb.org
Corticosteroids can blunt growth hormone response to GHRH stimulation. Patients on corticosteroids require dose adjustment consideration.
Active or prior malignancy is a contraindication due to growth hormone's mitogenic properties. See FDA compounding guidance: https://www.fda.gov/drugs/human-drug-compounding
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Sources & References
Frequently Asked Questions
How does Sermorelin differ from direct growth hormone therapy?
Sermorelin stimulates the body's own pituitary gland to produce GH naturally and in a pulsatile pattern, rather than introducing exogenous GH. This is generally considered to have a more favorable safety profile and avoids the regulatory restrictions on direct GH prescribing.
Why is corticosteroid use a contraindication?
Glucocorticoids suppress the GH axis and reduce pituitary responsiveness to GHRH stimulation, which would diminish Sermorelin's therapeutic effect. Providers should evaluate whether the corticosteroid therapy can be tapered or adjusted.