BLOOD test referral for new patients I am on TRT * Yes No I am new to XY * Yes, proceed I am an existing XY patient - stop and contact us. Medicare Number * We collect your Medicare for identification purposes Line number * The number next to your name Expiry Date * Name * As it appears on your Medicare Card First Name Last Name Date of birth * MM DD YYYY Mobile Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country List your chronic medical conditions * (e.g. diabetes, hypertension, cardiovascular disease, hyperlipidaemia). List your current medications * (e.g. SSRIs, beta-blockers, anti-hypertensives or supplements) QADAM for HYPOGONADISM Rate out of 5 (1-terrible 2-poor 3-average 4-good 5-Excellent) Rate Strength * 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent) Rate Energy Level * 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent) Rate Libido (Sex Drive) * 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent) Rate Enjoyment in Life * 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent) Rate Happiness Level * 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent) Rate Erections * 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent) Rate Work Performance (Over Last 4 Weeks) * 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent) How Often Do You Fall Asleep Immediately After Dinner? * 1 - Always 2- Often 3 - Sometimes 4 - Rarely 5 - Never Rate Sports Ability/Training Over Last 4 Weeks * 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent) How Much Height Have You Lost? * As men age, they have poor posture and measure shorter for height. 1 - substantial height change 2 - very noticeable height change 3 - noticeable height change 4 - slight noticeable height change 5 - no height change Have you had difficulty getting or maintaining an erection? * YES NO Have you had severe headaches and/or blurred vision? * YES NO Have you had anxiety about sexual performance? * YES NO Have you had reduced sexual desire? * YES NO Have you had a raised PSA (Prostate Specific Antigen)? * YES NO NOT SURE Are you currently residing in Australia? * YES NO Do you understand once you submit this form, the doctor will call you (from a private number) in 48 business hours or less for a brief telehealth consult to confirm your identity and responses? * YES NO Do you understand you’ll get an SMS from a clinic (which might not be nearby or available in your state), but you can print the referral and go to any pathology clinic in Australia? * YES NO Do you understand you should print the referral BEFORE you go to the clinic in case there is a technical issue? * YES NO, I need assistance. Do you understand everything that is written above ? * YES NO, I need assistance. Will you visit your GP if your results are abnormal? * YES NO I confirm my answers are honest and accurate to the best of my knowledge. * YES Thank you for submitting your information. The doctor will call you in 48 business hours or less to confirm your identity and responses.
