all questions are mandantory Medicare Number * We collect your Medicare for identification purposes Expiry Date * Name * As it appears on your Medicare Card First Name Last Name Date of birth * MM DD YYYY Email * Mobile * (###) ### #### 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. QADAM for HYPOGONADISM Answer on how you currently feel to monitor symptom relief. 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 I have been diagnosed for: * Click all that apply. Obstructive sleep apneoa Benign prostatic hyperplasia Congestive heart failure Coronary artery disease Diabetes High Blood Pressure None of the above. List your current medical conditions IF NOT LISTED ABOVE * 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. List your prescription medications (strength and dose) * Write Nil Known if you do not take any prescription medications. 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 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 within three working days to discuss whether scheduling a doctor’s consultation 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.
