Complete our Questionnaire

Health Questionnaire and Patient Consent Agreement

In-depth Health History Questionnaire

Which service are you interested in?(Required)

Testosterone Replacement Therapy (TRT)

Weight Management Treatment (WMT)

Both TRT & WMT

Hormone Replacement Therapy (HRT - Women's hormone therapy - perimenopause/menopause/postmenopause)

Both HRT & WMT

Name(Required)

First Last

Preferred First Name

Date of birth(Required)

DD slash MM slash YYYY

Phone(Required)

Age(Required)

What is your gender?(Required)

Male

Female

Other

Prefer not to say

• Men’s Testosterone Replacement Therapy (TRT) for the assessment and management of male hypogonadism. • Women’s Hormone Replacement Therapy (HRT) for the assessment and management of perimenopause, menopause and post-menopause. Our services are condition-specific and delivered via Telehealth following clinical assessment. We do not provide gender transition or gender-affirming hormone therapy, fertility treatment, or management of Primary Ovarian Insufficiency (POI) in women under 40. Suitability for treatment is determined by the prescribing doctor following review of your medical history, screening and investigations.

Elite HRT is designed specifically for the assessment and management of perimenopause and menopause in women. If you are seeking Testosterone Replacement Therapy please return to “Which service are you interested in” and select the appropriate service.

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 PLEASE NOTE Reference number must be included with Medicare number) • 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, 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)

Please upload a simple form of proof of service below - such as a work ID, AHPRA screenshot, DVA card, or discharge letter. 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: 128 MB.

Email(Required)

How did you hear about us?(Required)

Referral

Google

Social Media

Other

Please 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

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)

What best describes your current menstrual status?(Required)

Regular cycles

Irregular cycles

Skipped cycles

No period for 3+ months

No period for 12+ months

Hysterectomy (uterus removed)

Oophorectomy (ovaries removed)

Other

Date of your last menstrual period (LMP)(Required)

Month

Day

Year

Are you currently breastfeeding or trying to conceive?(Required)

Yes

Is there any possibility that you may currently be pregnant?(Required)

Yes

Unsure

As there may be a possibility of pregnancy, please include a B-HCG (pregnancy test) with your blood test to confirm pregnancy status prior to assessment. This test can be added as an optional additional test when ordering your blood work through the iMedical portal.

You selected yes, please specify.(Required)

In the past 3-6 months have you experienced any of the following?(Required)

Select All

Hot flushes

Night sweats

Sleep disturbance

Mood changes/irritability

Anxiety

Brain fog/concentration issues

Fatigue/low energy

Vaginal dryness

Pain with intercourse

Reduced libido

Weight gain/abdominal fat changes

Joint aches

Thinning hair/dry skin

Loss of breast fullness

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

Breast cancer (current or past)

Ovarian cancer

Endometrial/uterine cancer

Any oestrogen-dependant cancer

Unexplained vaginal bleeding

Endometrial thickening/hyperplasia

Primary Ovarian Insufficiency (POI)

Early Menopause

DVT/pulmonary embolism

Thrombophilia/clotting disorder

Stroke/TIA

Coronary heart disease

Uncontrolled high blood pressure

Dementia

PCOS

Endometriosis

Cancer

None of the above

Other

Primary Ovarian Insufficiency (POI) is typically managed by an endocrinologist. If you are under 40 and have suspected or confirmed POI, our service may not be suitable for Telehealth management. Our team will review your submission and advise accordingly.

You selected Cancer, please specify.(Required)

Do you have a first-degree family history (mother, sister, daughter) of any of the following?(Required)

Breast cancer (current or past)

Ovarian cancer

Endometrial/uterine cancer

Known BRCA mutation

Early cardiovascular disease (before age 60)

Blood clotting disorders

None of the above

Age of diagnosis (if known)

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

Yes

Are you currently using any of the following medications or treatments?(Required)

Hormone therapy (oestrogen/progesterone)

Mirena IUD

Combined oral contraceptive pill

Progesterone-only pill

Testosterone (any form)

DHEA/Supplements marketed for hormones

GLP-1 receptor agonist/dual GLP-1/GIP therapy (e.g. semaglutide, tirzepatide)

Antidepressants (SSRI/SNRI)

Blood thinners

Metformin

None of the above

Other

Are you currently using any of the following medications or treatments?(Required)

Insulin

Sulphonylureas (e.g., gliclazide, glimepiride)

Metformin

GLP-1 receptor agonist/dual GLP-1/GIP therapy (e.g. semaglutide, tirzepatide)

Other diabetes medication(s)

None of the above

Other

Please list all current medications and over the counter supplements, 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

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

Medullary Thyroid Carcinoma

Pancreatitis

Gallbladder Disease

Severe Reflux (GORD/GERD)

Gastrointestinal Disease

Dyslipidaemia (high cholesterol/triglycerides)

Insulin Resistance or pre-diabetes

Type 1 Diabetes

Type 2 Diabetes

Low Testosterone

Infertility

Erectile Dysfunction

Varicocele

Prolactinoma

Adrenal Disorder

Heart Disease

Hypertension (High Blood Pressure)

Thyroid Disorders

Liver Disease

Kidney Disease

Cancer

Prostate Carcinoma

Asthma

Inflammatory Bowel Disease

Depression and/or Anxiety Disorders

Obstructive Sleep Apnoea (OSA)

PCOS

Endometriosis

None of the above

Other

You selected Other, please specify.(Required)

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

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

Medullary Thyroid Carcinoma

Pancreatitis

Gallbladder Disease

Dyslipidaemia (high cholesterol/triglycerides)

Insulin Resistance or pre-diabetes

Type 1 Diabetes

Type 2 Diabetes

Low Testosterone

Infertility

Erectile Dysfunction

Varicocele

Prolactinoma

Adrenal Disorder

Heart Disease

Hypertension (High Blood Pressure)

Thyroid Disorders

Liver Disease

Kidney Disease

Cancer

Prostate Carcinoma

Asthma

Inflammatory Bowel Disease

Depression and/or Anxiety Disorders

Obstructive Sleep Apnoea (OSA)

PCOS

Endometriosis

None of the above

Other

You selected Other, please specify.(Required)

You selected Cancer, please specify.(Required)

Have you ever felt the need to make yourself vomit after eating because you felt overly full or uncomfortable?(Required)

Yes

Do you sometimes feel that you lose control over how much you eat?(Required)

Yes

Have you unintentionally lost more than 6 kilograms in the past 3 months?(Required)

Yes

Do you often feel unhappy with your body size or shape, even when others tell you you're at a healthy weight?(Required)

Yes

Do you find that thoughts about food, eating, or your body take up a lot of your time or attention?(Required)

Yes

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

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

Persistent Fatigue or low energy level

Shortness of breath on exertion

Daytime sleepiness or poor sleep quality

Joint pain or reduced mobility from excess weight

Cravings or difficulty controlling appetite

Fluctuating blood sugar levels, dizziness, or shakiness after meals

Mood changes or emotional eating patterns

Gastrointestinal discomfort

Depression

Anxiety

Brain fog (difficulty concentrating etc)

Decreased Muscle mass

Increased Body fat

Decreased Stamina or Endurance

Low libido (reduced sex drive)

Erectile dysfunction

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?(Required)

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)

Are you currently on TRT?(Required)

Yes

Have you ever been on Testosterone Replacement Therapy (TRT)?(Required)

Yes

Please 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)

Cervical Screening Test(Required)

MM slash DD slash YYYY

Date of your most recent Cervical Screening Test

Please upload your recent CST result or confirmation

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.

A current Cervical Screening Test (within the last 5 years) is required prior to prescribing. If not uploaded now, it must be provided before treatment can commence.

Mammogram(Required)

MM slash DD slash YYYY

Date of your most recent Mammogram

Please upload your recent Mammogram result or confirmation

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.

A recent Mammogram (within the past 2 years) is required prior to prescribing. If not uploaded now, it must be provided before treatment can commence.

Need to purchase blood work? Click here to order your mandatory Elite 3 blood test.

Need to purchase blood work? Click here to order your mandatory Elite HRT blood test.

Need to purchase blood work? Click here to order your mandatory WMT blood test.

Please upload your recent Elite WMT bloodwork results (in their original PDF format) from within the last 3-months - please ensure your recent hbA1C, TSH/FT3/FT4, Lipase and Insulin results are included in your bloodwork (these are mandatory for WMT assessment).(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.

Please upload your recent Elite HRT blood work results in their original PDF format (please note recent blood tests must have been collected within the last three months in a fasted state). If you are supplying your own recent panels they must include every test in Elite HRT. If you are interested in weight management treatment (WMT) as well as Hormone Replacement Therapy (HRT) please include recent Lipase and Insulin results in your bloodwork (these are mandatory for WMT assessment). If there is any possibility that you may currently be pregnant, please include a B-HCG (pregnancy test) with your blood test to confirm pregnancy status prior to assessment. This can be added as an optional additional test when ordering your blood work through iMedical.(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.

If you are still having menstrual cycles, on which day of your cycle was your blood test performed?

My blood test was taken during my period

Within 5 days after my period ended

Around the middle of my cycle

Within 10 days before my next period

My cycles are irregular/I am unsure

Not applicable (no longer having periods)

Please upload both your recent Elite 3 and pre-TRT blood work results in their original PDF format (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. If you are interested in weight management treatment (WMT) as well at Testosterone Replacement Therapy (TRT) please include recent hbA1C, TSH/FT3/FT4, Lipase and Insulin results in your bloodwork (these are mandatory for WMT assessment).(Required)

Drop files here or

Accepted 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 in their original PDF format (please note both blood tests must have been collected within the last three months and morning collections for accurate baseline results). If you are supplying your own Panels they must include every test in both Elite 1 + Elite 2 and there must be two seperate Free & Total Testosterone + SHBG tests to determine baseline testosterone levels and assess for eligibility. If you are interested in weight management treatment (WMT) as well at Testosterone Replacement Therapy (TRT) please ensure to include recent hbA1C, TSH/FT3/FT4, Lipase and Insulin results in your bloodwork (these are mandatory for WMT assessment).(Required)

Drop files here or

Accepted 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

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: 128 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)

Waist Circumference (in CM)(Required)

Hip Circumference (in CM)(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?

Consent and Acknowledgements

Please 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 understand

If eligible for weight management treatment (WMT), do you understand that meeting the initial BMI or screening criteria does not guarantee eligibility, and that final approval is at the doctors discretion following a medical consultation(Required)

Yes I understand

If eligible for hormone replacement therapy (HRT), do you understand that meeting the initial screening criteria does not guarantee eligibility, and that final prescribing decisions are made by the doctor following review of your questionnaire, bloodwork and consultation?(Required)

Yes I understand

Do you understand that weight management 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

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)
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.

Patient Consent and Disclosure Agreement(Required)

Purpose of Hormone Replacement Therapy (HRT)

Hormone Replacement Therapy (HRT) is intended to manage symptoms associated with perimenopause, menopause and post-menopause, by addressing changes in hormone levels.

The aim of treatment is to reduce symptoms such as hot flushes, night sweats, sleep disturbance, mood changes, vaginal dryness and reduced libido.

Individual outcomes vary, and symptom improvement cannot be guaranteed.

Potential Benefits and Risks of HRT

Potential Benefits
• Reduction in vasomotor symptoms (e.g. hot flushes, night sweats)
• Improved sleep and mood stability
• Improved vaginal and urogenital symptoms
• Maintenance of bone density
• Potential improvement in overall quality of life

Potential Risks

HRT may not be suitable for everyone. Potential risks and side effects may include:
• Breast tenderness
• Irregular or breakthrough bleeding
• Fluid retention
• Headaches
• Mood changes
• Increased risk of thrombosis (particularly with oral therapies)
• Small increased risk of breast cancer with prolonged combined therapy
• Other individualised risks based on medical history

Suitability for HRT is determined by the prescribing doctor based on your questionnaire, medical history, bloodwork, screening results and overall risk profile.

EliteTRT will monitor your health through appropriate bloodwork, screening requirements and follow-up consultations.

Telehealth Consent

You consent to receiving HRT services via Telehealth (telephone consultation).

You understand that:
• Consultations will be conducted via telephone.
• You are responsible for ensuring you are in a private environment during the call.
• There may be limitations compared to in-person assessments.
• Certain investigations or referrals may be required through your GP or specialist where clinically indicated.
• Technical disruptions may occasionally occur and may require rescheduling if the consultation cannot be safely completed.

Data Handling and Confidentiality

EliteTRT adheres to Australian privacy legislation in the secure storage and management of personal and health information.

Your consent includes:
• Secure storage of medical records
• Secure handling of pathology results
• Secure transmission of eScripts
• Access limited to authorised clinic staff and prescribing doctors only

Prescription Fulfilment Options

Preferred Partner Pharmacy Fulfilment

If you choose this option:
• Your eScript will be sent directly to our preferred partner pharmacy for dispensing.
• You will not receive the eScript token directly while this option is selected.
• Medication will be prescribed in accordance with the doctor’s clinical plan.
• Follow-up consultations and/or bloodwork will be required at intervals determined by the prescribing doctor.
• Your fulfilment preference can be changed at any rescript review.

Self-Fulfilment

If you choose this option:
• Your eScript will be provided directly to you for dispensing at your preferred local pharmacy.
• You remain responsible for ensuring medication is dispensed and used strictly in accordance with the prescribing doctor’s directions.
• Ongoing monitoring and follow-up requirements remain the same regardless of dispensing location.

Monitoring and Ongoing Review

You agree to:
• Complete required blood tests as requested
• Remain up to date with recommended screening (including Cervical Screening Test and mammogram where applicable)
• Attend scheduled review consultations
• Notify the clinic of any significant changes in health status

Acknowledgement

By completing this form, you confirm that:
• You understand the purpose, potential benefits and risks of HRT
• You understand that eligibility and prescribing decisions are made solely by the doctor
• You agree to comply with EliteTRT’s clinical and monitoring requirements for safe 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 HRT, Telehealth consent, data handling, and prescription fulfilment options.

Patient Consent and Disclosure Agreement(Required)

Purpose of Weight Management Treatment (WMT)

WMT is intended to support medically supervised weight loss in individuals who meet clinical eligibility criteria, such as elevated BMI and weight-related comorbidities. Treatment aims to improve metabolic health and support sustainable weight reduction when combined with appropriate lifestyle measures. Individual outcomes vary.

Potential Benefits and Risks of WMT

Benefits:
Potential benefits may include improved blood sugar control, reduced appetite, gradual weight loss, improved cardiovascular markers, and enhanced overall wellbeing.

Risks:
Possible side effects may include nausea, reflux, constipation, diarrhoea, bloating, abdominal discomfort, headache, or fatigue. Serious but rare risks include pancreatitis, gallbladder issues, or thyroid-related complications. Treatment may not be suitable for individuals with a history of certain medical conditions (e.g. pancreatitis, severe gastrointestinal disease, or specific thyroid cancers).

EliteWMT doctors will monitor your health and progress through regular reviews and follow-up assessments.

Telehealth Consent

You consent to Telehealth services for your consultations, understanding the limitations and requirements for technology access needed to conduct secure and private appointments.

Data Handling and Confidentiality

EliteWMT adheres to Australian privacy and health data protection laws to securely store, manage, and transmit your medical information, including eScripts.
Your consent includes the secure storage of treatment records accessible only to authorised clinic staff.

Prescription Fulfilment Options

Preferred Partner Pharmacy Fulfilment:
If you choose this option, medication will be dispensed by EliteWMT’s partner pharmacy. Prescriptions are typically issued for a three-month supply. Regular check-ins, weight tracking, and clinical reviews are required for continued treatment. Patients will not receive a direct copy of the eScript after dispensing to prevent duplicate scripts. Fulfilment preferences can be updated at each review.

Self-Fulfilment:
Patients may choose to fill prescriptions at their preferred local pharmacy, following EliteWMT’s prescribing and monitoring guidelines.

Acknowledgement

By completing this form, you confirm your understanding of Weight Management Treatment (WMT), including the benefits, risks, and requirements, and agree to comply with EliteWMT’s medical and monitoring guidelines for safe and effective care.

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 WMT, Telehealth consent, data handling, and prescription fulfilment options.

Which service are you interested in?(Required)

Testosterone Replacement Therapy (TRT)

Weight Management Treatment (WMT)

Both TRT & WMT

Hormone Replacement Therapy (HRT - Women's hormone therapy - perimenopause/menopause/postmenopause)

Both HRT & WMT

Name(Required)

First Last

Preferred First Name

Date of birth(Required)

DD slash MM slash YYYY

Phone(Required)

Age(Required)

What is your gender?(Required)

Male

Female

Other

Prefer not to say

Please provide your Medicare and/or IHI number (Required for eScripts)(Required)

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: 128 MB.

Email(Required)

How did you hear about us?(Required)

Referral

Google

Social Media

Other

Please 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

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)

What best describes your current menstrual status?(Required)

Regular cycles

Irregular cycles

Skipped cycles

No period for 3+ months

No period for 12+ months

Hysterectomy (uterus removed)

Oophorectomy (ovaries removed)

Other

Date of your last menstrual period (LMP)(Required)

Month

Day

Year

Are you currently breastfeeding or trying to conceive?(Required)

Yes

Is there any possibility that you may currently be pregnant?(Required)

Yes

Unsure

You selected yes, please specify.(Required)

In the past 3-6 months have you experienced any of the following?(Required)

Select All

Hot flushes

Night sweats

Sleep disturbance

Mood changes/irritability

Anxiety

Brain fog/concentration issues

Fatigue/low energy

Vaginal dryness

Pain with intercourse

Reduced libido

Weight gain/abdominal fat changes

Joint aches

Thinning hair/dry skin

Loss of breast fullness

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

Breast cancer (current or past)

Ovarian cancer

Endometrial/uterine cancer

Any oestrogen-dependant cancer

Unexplained vaginal bleeding

Endometrial thickening/hyperplasia

Primary Ovarian Insufficiency (POI)

Early Menopause

DVT/pulmonary embolism

Thrombophilia/clotting disorder

Stroke/TIA

Coronary heart disease

Uncontrolled high blood pressure

Dementia

PCOS

Endometriosis

Cancer

None of the above

Other

You selected Cancer, please specify.(Required)

Do you have a first-degree family history (mother, sister, daughter) of any of the following?(Required)

Breast cancer (current or past)

Ovarian cancer

Endometrial/uterine cancer

Known BRCA mutation

Early cardiovascular disease (before age 60)

Blood clotting disorders

None of the above

Age of diagnosis (if known)

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

Yes

Are you currently using any of the following medications or treatments?(Required)

Hormone therapy (oestrogen/progesterone)

Mirena IUD

Combined oral contraceptive pill

Progesterone-only pill

Testosterone (any form)

DHEA/Supplements marketed for hormones

GLP-1 receptor agonist/dual GLP-1/GIP therapy (e.g. semaglutide, tirzepatide)

Antidepressants (SSRI/SNRI)

Blood thinners

Metformin

None of the above

Other

Are you currently using any of the following medications or treatments?(Required)

Insulin

Sulphonylureas (e.g., gliclazide, glimepiride)

Metformin

GLP-1 receptor agonist/dual GLP-1/GIP therapy (e.g. semaglutide, tirzepatide)

Other diabetes medication(s)

None of the above

Other

Please list all current medications and over the counter supplements, 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

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

Medullary Thyroid Carcinoma

Pancreatitis

Gallbladder Disease

Severe Reflux (GORD/GERD)

Gastrointestinal Disease

Dyslipidaemia (high cholesterol/triglycerides)

Insulin Resistance or pre-diabetes

Type 1 Diabetes

Type 2 Diabetes

Low Testosterone

Infertility

Erectile Dysfunction

Varicocele

Prolactinoma

Adrenal Disorder

Heart Disease

Hypertension (High Blood Pressure)

Thyroid Disorders

Liver Disease

Kidney Disease

Cancer

Prostate Carcinoma

Asthma

Inflammatory Bowel Disease

Depression and/or Anxiety Disorders

Obstructive Sleep Apnoea (OSA)

PCOS

Endometriosis

None of the above

Other

You selected Other, please specify.(Required)

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

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

Medullary Thyroid Carcinoma

Pancreatitis

Gallbladder Disease

Dyslipidaemia (high cholesterol/triglycerides)

Insulin Resistance or pre-diabetes

Type 1 Diabetes

Type 2 Diabetes

Low Testosterone

Infertility

Erectile Dysfunction

Varicocele

Prolactinoma

Adrenal Disorder

Heart Disease

Hypertension (High Blood Pressure)

Thyroid Disorders

Liver Disease

Kidney Disease

Cancer

Prostate Carcinoma

Asthma

Inflammatory Bowel Disease

Depression and/or Anxiety Disorders

Obstructive Sleep Apnoea (OSA)

PCOS

Endometriosis

None of the above

Other

You selected Other, please specify.(Required)

You selected Cancer, please specify.(Required)

Have you ever felt the need to make yourself vomit after eating because you felt overly full or uncomfortable?(Required)

Yes

Do you sometimes feel that you lose control over how much you eat?(Required)

Yes

Have you unintentionally lost more than 6 kilograms in the past 3 months?(Required)

Yes

Do you often feel unhappy with your body size or shape, even when others tell you you're at a healthy weight?(Required)

Yes

Do you find that thoughts about food, eating, or your body take up a lot of your time or attention?(Required)

Yes

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

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

Persistent Fatigue or low energy level

Shortness of breath on exertion

Daytime sleepiness or poor sleep quality

Joint pain or reduced mobility from excess weight

Cravings or difficulty controlling appetite

Fluctuating blood sugar levels, dizziness, or shakiness after meals

Mood changes or emotional eating patterns

Gastrointestinal discomfort

Depression

Anxiety

Brain fog (difficulty concentrating etc)

Decreased Muscle mass

Increased Body fat

Decreased Stamina or Endurance

Low libido (reduced sex drive)

Erectile dysfunction

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?(Required)

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)

Are you currently on TRT?(Required)

Yes

Have you ever been on Testosterone Replacement Therapy (TRT)?(Required)

Yes

Please 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)

Cervical Screening Test(Required)

MM slash DD slash YYYY

Date of your most recent Cervical Screening Test

Please upload your recent CST result or confirmation

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.

A current Cervical Screening Test (within the last 5 years) is required prior to prescribing. If not uploaded now, it must be provided before treatment can commence.

Mammogram(Required)

MM slash DD slash YYYY

Date of your most recent Mammogram

Please upload your recent Mammogram result or confirmation

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.

A recent Mammogram (within the past 2 years) is required prior to prescribing. If not uploaded now, it must be provided before treatment can commence.

Need to purchase blood work? Click here to order your mandatory Elite 3 blood test.

Need to purchase blood work? Click here to order your mandatory Elite HRT blood test.

Need to purchase blood work? Click here to order your mandatory WMT blood test.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.

If you are still having menstrual cycles, on which day of your cycle was your blood test performed?

My blood test was taken during my period

Within 5 days after my period ended

Around the middle of my cycle

Within 10 days before my next period

My cycles are irregular/I am unsure

Not applicable (no longer having periods)

Drop files here or

Accepted 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.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 128 MB.

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: 128 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)

Waist Circumference (in CM)(Required)

Hip Circumference (in CM)(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?

Consent and Acknowledgements

Please 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 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 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)