EliteTRT Health Questionnaire and Patient Consent AgreementIn-depth Health History QuestionnaireIn-depth Health History QuestionnaireName(Required) First Last Date of birth(Required) DD slash MM slash YYYY Phone(Required)Please provide your Medicare and/or IHI number (Required for eScripts)(Required)To process your prescriptions efficiently, we require your Medicare Number and/or Individual Healthcare Identifier (IHI) Number. These details are necessary for our doctors to issue eScripts. • Medicare Number: (Enter your 10-digit Medicare number and the Individual Reference Number – the small number next to your name on your Medicare card) • IHI Number (if applicable): (Your Individual Healthcare Identifier, which you can find via your MyGov account under Medicare details)Are you a current or former first responder or member of the Australian Defence Force?Includes police, firefighters, paramedics, and veterans (current/ex serving) Yes NoPlease upload proof of your service (for our $100 Annual Service Fee Discount)Accepted forms of ID include: – Police, fire, or ambulance employee ID – Paramedic registration (AHPRA or state-issued) – Military ID – DVA White Card or Gold Card. This information is used only to verify your eligibility and will remain strictly confidential. Drop files here or Select filesMax. file size: 128 MB.Email(Required) How did you hear about us?(Required) Referral Google Social Media OtherPlease provide information i.e name of person/company/social media/other who referred you.Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Do you currently have a primary healthcare provider? (GP, family doctor, etc.)(Required) Yes NoWhat was your most recent blood pressure reading? Include date and time last reading was done.(Required)Please provide your healthcare provider’s name and contact information.(Required)Are you currently taking any Medications and/or Supplements?(Required) Yes NoPlease list all current medications and over the counter supplements, include dosages and frequency.(Required)Do you have any known allergies?(Required) Yes NoPlease specify all known allergies.(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 OtherYou selected Other, 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 OtherYou selected Other, 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 OtherYou 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 yearHave you consulted a healthcare provider about these symptoms?(Required) Yes NoWhat was your diagnosis and the treatment that was recommended?(Required)Have you ever taken any performance-enhancing drugs (PEDs) or anabolic steroids?(Required) Yes NoPlease specify which substances, duration of use, and date of last use.(Required)Are you currently on TRT?(Required) Yes NoHave you ever been on Testosterone Replacement Therapy (TRT)?(Required) Yes NoPlease provide details of the TRT regimen you were on, including provider (clinic name and website link if applicable or GP/Endocrinologist), list all medications - dosages and frequency.(Required)Please provide details of your current TRT regimen, including provider (clinic name and website link if applicable or GP/Endocrinologist), list all medications - dosages and frequency.(Required)Need to purchase blood work? Click here to order your mandatory Elite 3 blood test.Please upload both your recent Elite 3 and pre-TRT blood work results (please note recent blood tests must have been collected within the last three months) . If you are supplying your own recent Panels they must include every test in Elite 3 and you must also include seperate bloodwork indicating low testosterone levels prior to commencing TRT.(Required) Drop files here or Select filesAccepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.Need to purchase blood work? Click here to order your mandatory Elite 1 blood test.Need to purchase blood work? Click here to order your mandatory Elite 2 blood test.Please upload both your recent Elite 1 and Elite 2 bloodwork results (please note both blood tests must have been collected within the last three months). If you are supplying your own Panels they must include every test in both Elite 1 + Elite 2 and there must be two seperate testosterone tests to determine low testosterone levels.(Required) Drop files here or Select filesAccepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.Did you perform any intense resistance training in the days prior to your 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.(Required)Are you planning to have children in the future?(Required) Yes No UnsureWhen are you looking to conceive?(Required)Have you been diagnosed with infertility or have had any difficulty conceiving?(Required) Yes NoUpload Semen Analysis Results (if you have had your levels tested) Drop files here or Select filesAccepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.Do you smoke?(Required) Yes NoHow many cigarettes per day?(Required)Do you consume alcohol?(Required) Yes NoHow often and how many drinks per day/week?(Required)Do you use recreational drugs?(Required) Yes NoPlease specify all types and frequency of use?(Required)Do you exercise regularly?(Required) Yes NoPlease describe the type, frequency, and duration of your exercise routine(Required)How would you describe your nutrition?(Required) Poor Average GreatTotal Daily Caloric intake if knownDaily 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 aboveHave you been diagnosed with a sleep disorder (e.g., sleep apnoea, insomnia)?(Required) Yes NoPlease 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?Consent and AcknowledgementsPlease read the following consent and acknowledgment sections carefully before proceeding.If eligible for TRT, do you understand that it may have potential side effects, including changes in mood, increased red blood cell count, and impact on fertility?(Required) Yes I understandIf eligible for TRT, do you agree to undergo regular blood tests and follow-up consultations as part of your TRT treatment plan?(Required) Yes I agreeYou acknowledge that EliteTRT is a private practice and services provided are not covered by Medicare or private health insurance rebates.(Required) Yes I acknowledgeIf eligible for TRT, do you consent to EliteTRT 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 EliteTRT’s partner pharmacies) No (I prefer to fill my script at my local chemist)You (if eligible for TRT) 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 acknowledgeConsent to Securely Store Prescription Information(Required)For continuity of care and as a backup in case of loss, we can securely store a copy of your electronic prescription (eScript) in our clinic records. This will allow us to refer to your prescription during consultation calls and provide a replacement if needed. Your information will be stored in accordance with Australian privacy laws and accessible only to authorised clinic staff. Yes, I consent to EliteTRT securely storing a copy of my eScript No, I do not consent to EliteTRT storing a copy of my eScriptYou acknowledge that a consultation with a practitioner via EliteTRT does not guarantee a diagnosis, prescription, or specific treatment. Practitioners exercise their clinical discretion to determine the appropriateness of any service.(Required) Yes I acknowledgeYou 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 confirmPatient Consent and Disclosure Agreement(Required)Purpose of Testosterone Replacement Therapy (TRT) TRT is intended to treat symptoms of hypogonadism, aiming to restore hormone levels and improve symptoms like fatigue, low libido, and muscle weakness. Individual outcomes vary. Potential Benefits and Risks of TRT Benefits: Potential improvements in energy, mood, libido, muscle strength, and cognitive focus. 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.
