NEW PATIENT QUESTIONNAIRE Medicare Number * We collect your Medicare for identification purposes What is your line number on your Medicare Card? * 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 Occupation Provide details for your regular GP or the GP/Clinic you last visited. * List your allergies & intolerances. * Write Nil Known if you do not have any. I am on TRT * YES NO 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 Do you have any obstructive urinary symptoms such as slow, prolonged or difficult urination? * YES NO I have been diagnosed for Obstructive Sleep Apneoa * YES NO I have been diagnosed for Benign Prostatic Hyperplasia * YES NO I have been diagnosed for Congestive Heart Failure * YES NO I have been diagnosed for Coronary Artery Disease * YES NO I have been diagnosed for Diabetes * YES NO I have been diagnosed for High Blood Pressure * YES NO List ANY OTHER chronic medical conditions * List your current medications (strength and dose) * Write Nil Known if you do not take any prescription medications. Do you sometimes take Opioids or Glucocorticoids? * Opioids - e.g. Endone or Oxycontin or Glucocorticoids - e.g. Prednisolone or Dexamethasone Have you ever been diagnosed with cancer? * Write NIL KNOWN if you never been diagnosed with cancer List family history of medical conditions or cancer for your immediate family members. * Write NIL KNOWN if not applicable. Do you smoke or vape? * YES NO How often do you drink alcohol? * I do not drink alcohol I rarely drink. I drink often. How tall are you in cm? * How much do you weigh in kg? * How Often Do You Exercise? I do not exercise. 1-2 times per week 3-4 times per week More than 5 times per week Are you planning to have more children? * NO YES Do you understand everything that is written above? * YES NO, I need assistance. I confirm my answers are honest and accurate to the best of my knowledge. * YES Thank you for submitting your information. Our team will review them and contact you on Mondays and Tuesdays to discuss whether scheduling a doctor’s consultation on Wednesday for TRT is appropriate. In the meantime, we encourage you to read more about TRT on our website, including this article on costs, benefits, and risks: https://xytherapeutics.com.au/articles/trt-costs-benefits-risks.
