Do you need a review consult with your doctor? Complete the following. The first follow-up consultation does not require a blood panel. However, every quarterly review will need the minimum panel to prevent complications. If you source your own blood tests, have them ready in PDF format before proceeding. Ensure you have the minimum panel - missing tests will delay your booking. MINIMUM PANEL: Testosterone, , Free Test. (calc), Oestradiol, SHBG. FSH, LH, Prolactin, FBE (Full Blood Examination), LFT (Liver function tests), Blood glucose EUC (Kidney function tests) *PSA and Calcium is required every 12 months. Name * First Name Last Name Date of birth * MM DD YYYY Email * Mobile * (###) ### #### List any issues or concerns you would like to discuss with the doctor: * Write 'NONE' if you do not have any. Please list your current prescription medicines: * Write 'NONE' if you do not take any. Answer based on how you feel currently to track our 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 Is this your first follow-up consult? Choose only one: * Yes - XY will confirm if blood tests are required. Proceed to SUBMIT. No, I've had multiple dr consults - XY organises my blood tests referral, Please arrange iScreen to email the referral invoice. Proceed to SUBMIT. No, I've had multiple dr consults - Please allow XY to organise my blood test referrals with iScreen. (Review Panel $159, Yearly Panel $185). Proceed to SUBMIT. No, I've had multiple dr consults - I provide my own panel and will upload my tests. I acknowledge I require the panel below and there will be delays if I am missing any tests. Proceed to UPLOAD. Thank you! We will contact you shortly.
