I am an existing patient. * Yes, proceed No, this is the incorrect form - STOP and contact us Name * First Name Last Name Date of birth * MM DD YYYY Mobile Email * 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 Are you experiencing any side effect/s? * NO YES Please list your current prescription medicines * Write 'NONE' if you do not take any. What is your blood pressure * When was this blood pressure reading taken? * MM DD YYYY What is your weight in Kg? * What is your height in cm? * Are you taking your testosterone/treatment exactly as prescribed? * YES NO Are you currently residing in Australia? * YES NO For regulatory compliance, we send treatment letters directly to your GP clinic. Please enter the email address of the most recent GP clinic you attended. * Do you understand everything that is written above? * YES NO, I need assistance. PLEASE READ - We will prepare your notes on Mondays and Tuesdays and may contact you for confirmation. Doctor invoices are typically sent before the doctor’s Wednesday consultation. You will receive a booking confirmation once the invoice is settled. dr review consult FORM
