Complete our Questionnaire

Health Questionnaire and Patient Consent Agreement

In-depth Health History Questionnaire

• Men’s Testosterone Replacement Therapy (TRT) for the assessment and management of male hypogonadism. Our services are condition-specific and delivered via Telehealth following clinical assessment. We do not provide gender transition or gender-affirming hormone therapy. Suitability for treatment is determined by the prescribing doctor following review of your medical history, screening and investigations.

Name(Required)

First Last

Preferred First Name

Date of birth(Required)

Day

Month

Year

Phone(Required)

Email(Required)

How did you hear about us?(Required)

Word of mouth

Google

Social Media

Business Card

Other

Please provide where you heard about us, if known.

Please provide where you received the business card, if known.

Please provide your 10-digit Medicare number (Required for eScripts and Pathology referrals)(Required)

To process your prescriptions efficiently, we require your Medicare Number. These details are necessary for our doctors to issue eScripts and Pathology referrals.

Please provide your Medicare Individual Reference Number (Required for eScripts and Pathology Referrals)(Required)

Medicare Individual Reference Number (IRN) - the small number next to your name on your Medicare card PLEASE NOTE Reference number must be included with Medicare number)

Are you a current or former first responder or member of the Australian Defence Force?

Includes Police, Firefighters, Paramedics, Registered Nurses and Veterans (current/ex serving), Prison Officers, Customs Officers, and Government-Accredited Dog Handlers.

Yes

Please provide your registration or service details below to confirm eligibility for our First Responder/Veteran discount.(Required)

If you’re a Registered Nurse or Paramedic, please enter your AHPRA registration number. If you’re a Police Officer, Firefighter, or Veteran (current or ex-serving), please enter your badge number, service ID, or DVA number.

Please upload proof of your service (for our $25 Quarterly Service Fee Discount)(Required)

First Responder/Veteran service fee discount: $25 off the quarterly clinic service fee where eligibility is confirmed. This discount applies to the clinic service fee only and does not apply to doctor consultation fees, pathology costs, medication costs or pharmacy charges. Proof of service is required. Accepted proof may include a work ID, AHPRA registration screenshot, DVA card, military ID or discharge documentation. This information is used only to assess eligibility for the discount. Accepted forms of ID include: – Police, fire, or ambulance employee ID – AHPRA registration (for paramedics or nurses) – Military ID – DVA White Card or Gold Card This information is used solely to confirm your eligibility for our First Responder/Veteran discount and will remain strictly confidential. Thank you for your service - this is our way of recognising the vital role you play.

Drop files here or

Max. file size: 50 MB.

Have you had bloodwork done recently (within the last 3-months)?(Required)

Yes

Please upload your most recent results below. If you have any additional bloodwork results older than 3-months, you are welcome to upload these as well. Our team will review the information provided and advise whether any further pathology is required.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB.

Once you have completed this questionnaire, you will be provided an option to purchase an initial pathology referral for a morning Total Testosterone test. The referral fee is $30 and covers the doctor’s review of the information provided and preparation of the pathology referral. Once your result is received, further blood testing may be requested where clinically appropriate. If a comprehensive pathology referral is required, an additional $30 referral fee applies. Once the required pathology results are on file, we can proceed with arranging a consultation with the doctor where appropriate.

Are you currently on TRT?(Required)

Yes

Is your current TRT prescribed by a doctor?(Required)

Prescribed

Non-prescribed

Please provide details of your TRT regimen, including provider (clinic name and website link if applicable or GP/Endocrinologist), list all medications - dosages and frequency.(Required)

If you are currently prescribed TRT and would like to be assessed for a transition of your existing care to EliteTRT please provide documentation that outlines your original diagnosis and current treatment - this can include summary or travel letters, and/or photos of pharmacy labels on your medication boxes showing your name, prescribing doctor, and dosage. We’ll also need your pre-TRT bloodwork, along with any intra-treatment bloodwork (*please provide 2-3 panels if you have been on treatment for 12+ months), and your most recent blood test within the last three months. Once these are provided our doctor can review your history and current protocol to assess and facilitate a potential transfer of care.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB.

Did you perform any intense resistance training in the days prior to your recent blood test(s)? What was your hydration status on the morning of the test(s)? Any elevated stress levels in the preceding week? Include any additional information you feel are relevant to your results.

Have you ever taken any performance-enhancing drugs (PEDs) or anabolic steroids?(Required)

Yes

Please specify which substances, duration of use, and date of last use.(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you currently have a primary healthcare provider? (GP, family doctor, etc.)(Required)

Yes

Please provide your healthcare provider’s name and contact information.(Required)

Are you currently taking any Medications and/or Supplements?(Required)

Yes

Please list all current medications and over the counter supplements that are not listed above, include dosages and frequency.(Required)

Have you ever been diagnosed with any of the following conditions?(Required)

Low Testosterone/Hypogonadism

Infertility

Erectile Dysfunction

Varicocele

Prolactinoma

Adrenal Disorder

Heart Disease

High Blood Pressure

Diabetes (Type 1 or 2)

Thyroid Disorders

Liver Disease

Kidney Disease

Cancer

Prostate Carcinoma

Asthma

Inflammatory Bowel Disease

Depression and/or Anxiety Disorders

Sleep Apnoea

None of the above

Other

You selected Other, please specify.

You selected Cancer, please specify.(Required)

Do you have a family history of any of the following conditions?(Required)

Low Testosterone/Hypogonadism

Heart Disease

High Blood Pressure

Diabetes (Type 1 or 2)

Thyroid Disorders

Liver Disease

Kidney Disease

Cancer

Prostate Carcinoma

Depression and/or Anxiety Disorders

Sleep Apnoea

None of the above

Other

You selected Other, please specify.(Required)

You selected Cancer, please specify.(Required)

Are you experiencing any of the following symptoms?(Required)

Fatigue

Low libido (reduced sex drive)

Erectile dysfunction

Depression

Anxiety

Brain fog (difficulty concentrating etc)

Decreased Muscle mass

Increased Body fat

Decreased Stamina or Endurance

None of the above

Other

You selected Other, please specify.(Required)

How long have you been experiencing these symptoms?(Required)

Less than 6 months

6 months - 1 year

More than 1 year

Have you consulted a healthcare provider about the symptoms you are experiencing?(Required)

Yes

What was the diagnosis (if applicable) and the treatment that was recommended?

Are you planning to have children in the future?(Required)

Yes

Unsure

When are you looking to conceive?(Required)

Have you been diagnosed with infertility or have had any difficulty conceiving?(Required)

Yes

Men please upload your recent Semen Analysis Results (if you have had your levels tested)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB.

What was your most recent blood pressure reading? Include date and time last reading was done.(Required)

Do you have any known Allergies?(Required)

Yes

Please list all allergies and the type of reaction you experience.(Required)

Do you smoke?(Required)

Yes

How many cigarettes per day?(Required)

Do you consume alcohol?(Required)

Yes

How often and how many drinks per day/week?(Required)

Do you use recreational drugs?(Required)

Yes

Please specify all types and frequency of use?(Required)

Height (in CM - Number only)(Required)

Weight (in KG - Number only)(Required)

BMI(Required)

Body Fat percentage (if known)

Do you exercise regularly?(Required)

Yes

Please describe the type, frequency, and duration of your exercise routine(Required)

How would you describe your nutrition?(Required)

Poor

Average

Great

Total Daily Caloric intake if known

Daily Protein intake (in grams)

Daily Carbohydrate intake (in grams)

Daily Fat intake (in grams)

How many litres of water do you drink daily on average?(Required)

Do you experience any of the following sleep issues?(Required)

Difficulty falling asleep

Frequent waking during the night

Snoring

Feeling unrested in the morning

None of the above

Have you been assessed for and/or diagnosed with a sleep disorder (e.g., sleep apnoea, insomnia)?(Required)

Yes

Please provide details and what treatment you are undergoing for sleep disorder(s)(Required)

Any other information you would like to share prior to submitting your health questionnaire?

Which of the following pathology providers has a collection centre accessible to you?(Required)

Australian Clinical Labs (ACL)

QML Pathology

Laverty Pathology

Clinpath

Douglass Hanly Moir

Sullivan Nicolaides Pathology

More than one of the above

None of the above/Unsure

Other

An Australian Clinical Labs (ACL) pathology referral will typically be provided, which can generally be presented at pathology collection centres Australia-wide. We ask which provider is most accessible to you for administrative purposes, as this helps our team locate and follow up your results if required. Your selection does not restrict where you can have your blood collected.

Consent and Acknowledgements

Please read the following consent and acknowledgment sections carefully before proceeding.

Do you understand that, if applicable, testosterone replacement medications may have potential side effects and may not be suitable for everyone based on their health history, current medications, or screening results?(Required)

Yes I understand

If eligible for treatment with our clinic, do you agree to undergo regular blood tests and follow-up consultations as part of your treatment plan?(Required)

Yes I agree

You acknowledge that we are a private practice and services provided are not covered by Medicare or private health insurance rebates.(Required)

Yes I acknowledge

Do you understand that pathology referral fees are non-refundable and that completing pathology testing does not guarantee eligibility for TRT. Treatment suitability is determined by the doctor following appropriate clinical assessment(Required)

Yes I understand

If eligible for treatment, do you consent to us sending your script to our preferred partner pharmacies to be held and fulfilled, or would you prefer to fill your script at your local chemist?(Required)

Yes (I consent to having my script sent to our partner pharmacy)

No (I prefer to fill my script at my local chemist)

You (if eligible for treatment) acknowledge that if you choose to have your script filled with our partner pharmacy, it will be held there and not accessible until your doctor reviews your blood work and, if eligible, approves a script renewal. After approval, you may opt to self-fulfill by taking the script to a local pharmacy. No duplicate scripts will be issued.(Required)

Yes I acknowledge

You acknowledge that a consultation with our practitioners does not guarantee a diagnosis, prescription, or specific treatment. Practitioners exercise their clinical discretion to determine the appropriateness of any service.(Required)

Yes I acknowledge

You confirm that all information provided in this questionnaire is accurate and complete. Failure to provide accurate information may result in the denial of services.(Required)

Yes I confirm

Patient Consent and Disclosure Agreement(Required)

Purpose of Testosterone Replacement Therapy (TRT)

Where clinically indicated, TRT may be prescribed with the aim of restoring testosterone levels into an appropriate therapeutic range. Symptom response varies and cannot be guaranteed.

Potential Benefits and Risks of TRT

Benefits: Potential benefits, risks and alternatives will be discussed with the prescribing doctor. Individual symptom response varies and cannot be guaranteed.

Risks: Side effects may include acne, fluid retention, changes in cholesterol, increased red blood cell count, gynecomastia, reduced fertility, mood swings, and others.

EliteTRT will monitor your health through regular bloodwork and consultations.

Telehealth Consent
You consent to Telehealth services, understanding the limitations and requirements for technology access for secure consultations.

Data Handling and Confidentiality
EliteTRT adheres to Australian privacy laws to securely store and manage health data, including eScripts.
Your consent includes the secure storage of treatment records, accessible only to authorised clinic staff.

Prescription Fulfillment Options

Preferred Partner Pharmacy Fulfillment: If you choose this option, only enough medication for a three-month supply will be prescribed. Bloodwork and doctor reviews are required every three months. Patients will not receive a direct copy of the e-script after compounding, to prevent duplicate scripts. Fulfillment preferences can be revisited at each review.

Self-Fulfillment: Patients may opt to self-fulfill prescriptions at a local pharmacy, following EliteTRT’s guidelines on dosage and administration.

By completing this form, you confirm your understanding of TRT, including the benefits, risks, and requirements, and agree to comply with EliteTRT’s guidelines for safe and effective treatment.

I confirm that I have read, understood, and agree to the terms outlined in the Patient Consent and Disclosure Agreement, including the potential benefits and risks of TRT, Telehealth consent, data handling, and prescription fulfilment options.

Name(Required)

First Last

Preferred First Name

Date of birth(Required)

Day

Month

Year

Phone(Required)

Email(Required)

How did you hear about us?(Required)

Word of mouth

Google

Social Media

Business Card

Other

Please provide where you heard about us, if known.

Please provide where you received the business card, if known.

Please provide your 10-digit Medicare number (Required for eScripts and Pathology referrals)(Required)

To process your prescriptions efficiently, we require your Medicare Number. These details are necessary for our doctors to issue eScripts and Pathology referrals.

Please provide your Medicare Individual Reference Number (Required for eScripts and Pathology Referrals)(Required)

Medicare Individual Reference Number (IRN) - the small number next to your name on your Medicare card PLEASE NOTE Reference number must be included with Medicare number)

Are you a current or former first responder or member of the Australian Defence Force?

Includes Police, Firefighters, Paramedics, Registered Nurses and Veterans (current/ex serving), Prison Officers, Customs Officers, and Government-Accredited Dog Handlers.

Yes

Please provide your registration or service details below to confirm eligibility for our First Responder/Veteran discount.(Required)

Please upload proof of your service (for our $25 Quarterly Service Fee Discount)(Required)

Drop files here or

Max. file size: 50 MB.

Have you had bloodwork done recently (within the last 3-months)?(Required)

Yes

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB.

Are you currently on TRT?(Required)

Yes

Is your current TRT prescribed by a doctor?(Required)

Prescribed

Non-prescribed

Please provide details of your TRT regimen, including provider (clinic name and website link if applicable or GP/Endocrinologist), list all medications - dosages and frequency.(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB.

Have you ever taken any performance-enhancing drugs (PEDs) or anabolic steroids?(Required)

Yes

Please specify which substances, duration of use, and date of last use.(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you currently have a primary healthcare provider? (GP, family doctor, etc.)(Required)

Yes

Please provide your healthcare provider’s name and contact information.(Required)

Are you currently taking any Medications and/or Supplements?(Required)

Yes

Please list all current medications and over the counter supplements that are not listed above, include dosages and frequency.(Required)

Have you ever been diagnosed with any of the following conditions?(Required)

Low Testosterone/Hypogonadism

Infertility

Erectile Dysfunction

Varicocele

Prolactinoma

Adrenal Disorder

Heart Disease

High Blood Pressure

Diabetes (Type 1 or 2)

Thyroid Disorders

Liver Disease

Kidney Disease

Cancer

Prostate Carcinoma

Asthma

Inflammatory Bowel Disease

Depression and/or Anxiety Disorders

Sleep Apnoea

None of the above

Other

You selected Other, please specify.

You selected Cancer, please specify.(Required)

Do you have a family history of any of the following conditions?(Required)

Low Testosterone/Hypogonadism

Heart Disease

High Blood Pressure

Diabetes (Type 1 or 2)

Thyroid Disorders

Liver Disease

Kidney Disease

Cancer

Prostate Carcinoma

Depression and/or Anxiety Disorders

Sleep Apnoea

None of the above

Other

You selected Other, please specify.(Required)

You selected Cancer, please specify.(Required)

Are you experiencing any of the following symptoms?(Required)

Fatigue

Low libido (reduced sex drive)

Erectile dysfunction

Depression

Anxiety

Brain fog (difficulty concentrating etc)

Decreased Muscle mass

Increased Body fat

Decreased Stamina or Endurance

None of the above

Other

You selected Other, please specify.(Required)

How long have you been experiencing these symptoms?(Required)

Less than 6 months

6 months - 1 year

More than 1 year

Have you consulted a healthcare provider about the symptoms you are experiencing?(Required)

Yes

What was the diagnosis (if applicable) and the treatment that was recommended?

Are you planning to have children in the future?(Required)

Yes

Unsure

When are you looking to conceive?(Required)

Have you been diagnosed with infertility or have had any difficulty conceiving?(Required)

Yes

Men please upload your recent Semen Analysis Results (if you have had your levels tested)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB.

What was your most recent blood pressure reading? Include date and time last reading was done.(Required)

Do you have any known Allergies?(Required)

Yes

Please list all allergies and the type of reaction you experience.(Required)

Do you smoke?(Required)

Yes

How many cigarettes per day?(Required)

Do you consume alcohol?(Required)

Yes

How often and how many drinks per day/week?(Required)

Do you use recreational drugs?(Required)

Yes

Please specify all types and frequency of use?(Required)

Height (in CM - Number only)(Required)

Weight (in KG - Number only)(Required)

BMI(Required)

Body Fat percentage (if known)

Do you exercise regularly?(Required)

Yes

Please describe the type, frequency, and duration of your exercise routine(Required)

How would you describe your nutrition?(Required)

Poor

Average

Great

Total Daily Caloric intake if known

Daily Protein intake (in grams)

Daily Carbohydrate intake (in grams)

Daily Fat intake (in grams)

How many litres of water do you drink daily on average?(Required)

Do you experience any of the following sleep issues?(Required)

Difficulty falling asleep

Frequent waking during the night

Snoring

Feeling unrested in the morning

None of the above

Have you been assessed for and/or diagnosed with a sleep disorder (e.g., sleep apnoea, insomnia)?(Required)

Yes

Please provide details and what treatment you are undergoing for sleep disorder(s)(Required)

Any other information you would like to share prior to submitting your health questionnaire?

Which of the following pathology providers has a collection centre accessible to you?(Required)

Australian Clinical Labs (ACL)

QML Pathology

Laverty Pathology

Clinpath

Douglass Hanly Moir

Sullivan Nicolaides Pathology

More than one of the above

None of the above/Unsure

Other

Consent and Acknowledgements

Please read the following consent and acknowledgment sections carefully before proceeding.

Yes I understand

If eligible for treatment with our clinic, do you agree to undergo regular blood tests and follow-up consultations as part of your treatment plan?(Required)

Yes I agree

You acknowledge that we are a private practice and services provided are not covered by Medicare or private health insurance rebates.(Required)

Yes I acknowledge

Yes I understand

Yes (I consent to having my script sent to our partner pharmacy)

No (I prefer to fill my script at my local chemist)

Yes I acknowledge

You confirm that all information provided in this questionnaire is accurate and complete. Failure to provide accurate information may result in the denial of services.(Required)

Yes I confirm

Patient Consent and Disclosure Agreement(Required)