Home/Health questionnaire

Health questionnaire

Your information.
A considered assessment.

Complete your health questionnaire and patient consent, and upload your existing pathology or treatment documents through the secure form below.

In-depth Health History Questionnaire

• Testosterone Replacement Therapy (TRT):
For the medical assessment and management of male hypogonadism. Recent blood tests are required before a TRT assessment can be completed.

• Men’s Sexual Health:
For the assessment and management of erectile dysfunction (ED) and premature ejaculation (PE). Initial blood tests are not routinely required.

• Men’s Hair Loss:
For the assessment and management of male pattern hair loss. Initial blood tests are not routinely required.

• Weight Management:
For the medical assessment of weight management for men. Initial blood tests are not routinely required.

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.

Which service are you interested in?(Required)

Testosterone Replacement Therapy (TRT)

Men’s Sexual Health

Men’s Hair Loss

Weight Management

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)

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.

A current pharmacy dispensing label clearly showing your printed name and current medication, or current clinical information from your treating clinic or doctor, can support your transfer review. Please also provide the pathology and treatment history requested above. The doctor may request further information before assessing a transfer.

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.

Recent unintentional weight loss(Required)

Yes

Have you unintentionally lost more than 6 kg in the past 3 months?

Loss of control over eating(Required)

Yes

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

Vomiting after eating(Required)

Yes

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

Concerns about body size or shape(Required)

Yes

Do you often feel unhappy with your body size or shape, even when others tell you that you are at a healthy weight?

Preoccupation with food or weight(Required)

Yes

Do thoughts about food, eating, weight or your body take up a significant amount of your time or attention?

Appetite and cravings(Required)

Yes

Do you experience frequent cravings or difficulty controlling your appetite?

Emotional eating(Required)

Yes

Do you experience emotional eating or eating in response to stress, mood or boredom?

Joint pain or mobility(Required)

Yes

Do you experience joint pain or reduced mobility associated with your weight?

Fatigue or low energy(Required)

Yes

Do you experience persistent fatigue or low energy?

Daytime sleepiness or poor sleep(Required)

Yes

Do you experience daytime sleepiness or poor sleep quality?

Previous weight-loss attempts(Required)

Yes

Have you previously attempted to lose weight through diet, exercise or lifestyle changes?

Please provide brief details of your previous weight-loss attempts.(Required)

Previous weight-management medication(Required)

Yes

Have you previously used prescription medication for weight management?

Which medication did you use, for how long, and did you experience any side effects?(Required)

Bariatric surgery or weight-loss procedures(Required)

Yes

Have you previously undergone bariatric surgery or another weight-loss procedure?

Please provide details, including the type of procedure and approximately when it was performed.(Required)

Eating disorder history(Required)

Yes

Have you ever been diagnosed with or treated for an eating disorder?

Pancreatitis or pancreatic disease(Required)

Yes

Have you ever been diagnosed with pancreatitis or another disease of the pancreas?

Gallstones or gallbladder disease(Required)

Yes

Have you ever been diagnosed with gallstones or gallbladder disease?

Gallbladder removal(Required)

Yes

Have you had your gallbladder surgically removed?

Thyroid Disease(Required)

Yes

Have you ever been diagnosed with a thyroid condition or thyroid disease?

Gastric emptying disorder(Required)

Yes

Have you ever been diagnosed with a gastric emptying disorder, such as gastroparesis?

Other gastrointestinal disease(Required)

Yes

Have you ever been diagnosed with another gastrointestinal disease or condition?

Further details(Required)

If you answered Yes to any of the above, please provide further details, including the condition, treatment received and current status.

Current medications and supplements(Required)

Do you currently take any prescription medications, over-the-counter medications or supplements? If yes, please provide details.

Medullary thyroid carcinoma/MEN2(Required)

Yes

Do you have a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN2)?

Previous reaction/allergy to weight-management medication(Required)

Yes

Have you ever had an allergic reaction to Mounjaro (tirzepatide), Ozempic (semaglutide), or another GLP-1/GIP medication?

Allergy/reaction details(Required)

Please provide details of the medication and the reaction you experienced.

Additional information(Required)

Is there anything else regarding your weight, appetite, eating patterns or previous weight-management treatment that you would like the doctor to know?

Duration of hair loss(Required)

Duration of hair loss How long have you noticed hair loss or thinning?

Location/pattern of hair loss(Required)

Frontal hairline/temples

Crown

Generalised thinning across the scalp

Patchy areas

Other

Where is your hair loss or thinning mainly occurring?

You selected other - please list the other area(s)(Required)

Rate of hair loss(Required)

Gradual - over several years

Moderate - over approximately 6-12 months

Rapid - over the past few months

Sudden onset

Unsure

How would you describe the rate at which your hair loss has occurred?

Previous hair transplant(Required)

Yes

Have you ever had a hair transplant?

Hair transplant details(Required)

Please provide brief details, including approximately when the procedure was performed.

Sudden or patchy hair loss(Required)

Yes

Have you experienced any sudden or patchy hair loss on your scalp, such as clearly defined, coin-sized areas?

Changes in hair texture(Required)

Yes

Have you noticed any changes in your hair texture, such as the hair becoming noticeably thinner, finer, more brittle or damaged?

Recent significant stressors(Required)

Yes

Have you experienced any significant stressors or major changes in your work, relationships or lifestyle recently?

Stressor details(Required)

Please provide brief details.

Eyebrow hair loss(Required)

Yes

Have you noticed any thinning or loss of hair from your eyebrows?

Previous hair-loss treatments(Required)

Yes

Have you previously used any treatments for hair loss, such as prescription or over-the-counter medication, topical treatments, PRP or specialised shampoos?

Previous treatment details(Required)

Please provide details of the treatment(s) used, how long you used them, the outcome, and any side effects you experienced.

Vitamin D deficiency(Required)

Yes

Have you ever been diagnosed with vitamin D deficiency?

Iron deficiency(Required)

Yes

Have you ever been diagnosed with iron deficiency?

Low blood pressure(Required)

Yes

Have you ever been diagnosed with low blood pressure (hypotension)?

Erectile dysfunction(Required)

Yes

Do you currently experience, or have you previously experienced, erectile dysfunction or difficulty achieving or maintaining an erection?

Scalp or skin conditions(Required)

Yes

Have you ever been diagnosed with eczema, dermatitis or another condition affecting your scalp or skin?

Other vitamin or nutritional deficiencies(Required)

Yes

Have you ever been diagnosed with another vitamin or nutritional deficiency?

Further details

If you answered Yes to any of the above, please provide further details.

Other medical history(Required)

Do you have any other past or current medical conditions? If yes, please provide details.

Current medications and supplements(Required)

Do you currently take any prescription medications, over-the-counter medications or supplements? If yes, please provide details.

Medication Allergies(Required)

Do you have any known medication or other allergies? If yes, please provide details.

Finasteride Allergy(Required)

Yes

Have you ever had an allergic reaction to finasteride?

Minoxidil Allergy(Required)

Yes

Have you ever had an allergic reaction to minoxidil?

Allergy/reaction details(Required)

If you selected yes to either allergy questions above - please provide details of the medication and the reaction you experienced.

Family history of hair loss(Required)

Yes

Unsure

Does hair loss or significant hair thinning affect anyone in your immediate family, such as your parents or siblings?

Family history details(Required)

Please provide brief details.

Treatment preference(Required)

Oral medication

Topical medication

No preference

Unsure - I would prefer to discuss the options with the doctor

If clinically appropriate and treatment options are available, would you prefer an oral or topical medication?

Additional information

Is there anything else regarding your hair loss, scalp health, previous treatments or medical history that you would like the doctor to know before your consultation?

Current Sexual health symptoms(Required)

Difficulty achieving an erection

Difficulty maintaining an erection

Premature ejaculation/ejaculating sooner than desired

Reduced libido/sexual desire

Other

What sexual health symptoms are you currently experiencing?

You selected Other(Required)

Please provide details.

Symptoms during masturbation and intercourse(Required)

During both

During masturbation only

During sexual activity with a partner only

Not applicable/unsure

Are these symptoms present during masturbation as well as sexual activity with a partner?

Duration of symptoms(Required)

How long have you been experiencing these symptoms?

Previous medication or treatment(Required)

Yes

Have you previously used any medications, therapies or other treatments for these symptoms?

Previous treatment details(Required)

Please provide details of what you have tried, how long you used it, whether it helped, and any side effects you experienced.

Difficulty achieving or maintaining erections(Required)

Yes

Do you experience difficulty achieving or maintaining an erection?

Erectile difficulty details(Required)

Please provide further details about the difficulties you experience.

Morning erections(Required)

Regularly

Occasionally

Rarely

Never

Unsure

Do you experience spontaneous erections upon waking?

Premature ejaculation(Required)

Yes

Do you experience premature ejaculation or ejaculation sooner than you would like?

Premature ejaculation details(Required)

Please provide further details, including approximately how soon ejaculation typically occurs and whether you feel you have difficulty controlling or delaying ejaculation.

Reduced libido(Required)

Yes

Have you noticed a reduction in your libido or sexual desire?

Frequency of symptoms(Required)

Every or almost every time

Most of the time

Approximately half the time

Occasionally

Rarely

How often do you experience the symptoms you have described?

Non-medication strategies(Required)

Yes

Have you tried any non-medication strategies or approaches that have improved your symptoms?

Details(Required)

Please provide details of what you have tried and whether it helped.

Low blood pressure(Required)

Yes

Have you ever been diagnosed with low blood pressure (hypotension)?

High blood pressure(Required)

Yes

Have you ever been diagnosed with high blood pressure (hypertension)?

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

Cardiovascular disease(Required)

Yes

Have you ever been diagnosed with cardiovascular disease, such as heart disease?

High cholesterol(Required)

Yes

Have you ever been diagnosed with high cholesterol?

Blood vessel disease(Required)

Yes

Have you ever been diagnosed with peripheral vascular disease or another blood vessel condition?

Mood disorders(Required)

Yes

Have you ever been diagnosed with or treated for anxiety, depression or another mood disorder?

Medical condition details(Required)

If you answered Yes to any of the above, please provide further details, including any current treatment.

Chest pain or dizziness(Required)

Yes

Do you experience chest pain or episodes of dizziness?

Details(Required)

Please provide further details.

Urinary symptoms(Required)

Yes

Do you experience any urinary symptoms, such as difficulty passing urine, incomplete bladder emptying, a weak urinary stream or other changes in urination?

Details(Required)

Please provide further details.

Current stress(Required)

Yes

Are you currently experiencing more stress than usual?

Stress details(Required)

Please provide brief details if you feel this may be relevant to your symptoms.

Other medical history(Required)

Do you have any other past or current medical conditions? If yes, please provide details.

Current medications and supplements(Required)

Do you currently take any prescription medications, over-the-counter medications or supplements? If yes, please provide details.

PDE5 inhibitor allergy(Required)

Yes

Have you ever had an allergic reaction to sildenafil (Viagra), tadalafil (Cialis), or another medication used to treat erectile dysfunction?

Details(Required)

Please provide details of the medication and reaction.

SSRI allergy(Required)

Yes

Have you ever had an allergic reaction to an SSRI antidepressant medication?

Details(Required)

Please provide details of the medication and reaction.

Additional information(Required)

Is there anything else regarding your sexual health, symptoms, previous treatment or medical history that you would like the doctor to know before your consultation?

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 - Number only)(Required)

Hip Circumference (in CM - Number only)(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 (SA)

Clinipath (WA)

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

Do you understand that, if applicable, medications used to manage sexual health concerns 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

Do you understand that, if applicable, medications used to manage hair loss 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

Do you understand that, if applicable, medications used for weight management 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 a prescription is issued after assessment, your eScript is sent directly to you. Which pharmacy arrangement would you prefer for dispensing?(Required)

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

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

Please select your pharmacy preference below. You may choose a pharmacy and pay its price for medication separately. Elite TRT does not add a medication markup.

I understand that if a prescription is issued following assessment, my eScript is sent directly to me. I may choose a pharmacy for dispensing and pay that pharmacy’s price for medication separately. Elite TRT does not add a medication markup. Prescribing and dispensing remain subject to clinical and pharmacy requirements.(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.

Electronic prescriptions and pharmacy choice

If your doctor issues a prescription following assessment, your eScript is sent directly to you. You may use a pharmacy of your choice, subject to its dispensing requirements and availability. Medication is paid for separately at that pharmacy’s price. Elite TRT does not add a markup to medication costs. Prescribing, quantity and review intervals remain the treating doctor’s clinical decision. A consultation does not guarantee a prescription.

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)

Men’s Sexual Health - Patient Consent and Disclosure Agreement

Purpose of Men’s Sexual Health Treatment

Where clinically indicated, treatment may be prescribed for conditions such as erectile dysfunction (ED) or premature ejaculation (PE). The prescribing doctor will determine whether treatment is clinically appropriate based on your symptoms, medical history, current medications and consultation.

Individual response to treatment varies and cannot be guaranteed.

Potential Benefits and Risks

Benefits: Treatment may assist with the management of diagnosed sexual health concerns. Potential benefits, risks, treatment options and alternatives will be discussed with the prescribing doctor.

Risks: Side effects vary depending on the medication prescribed and may include headache, flushing, dizziness, changes in blood pressure, gastrointestinal symptoms, nasal congestion, sexual side effects and other adverse effects. Some treatments may interact with other medications or be unsuitable for certain medical conditions.

You must provide accurate and complete information regarding your medical history, cardiovascular health, medications, allergies and any changes to your health.

Ongoing Care

Treatment suitability and the frequency of follow-up consultations will be determined by the prescribing doctor. Additional investigations or referral to another healthcare professional may be recommended where clinically appropriate.

Telehealth Consent

You consent to receiving healthcare services via telehealth and understand the limitations of remote consultations and the requirement for suitable technology and a private environment.

Data Handling and Confidentiality

EliteTRT handles personal and health information in accordance with applicable Australian privacy requirements. Treatment records, consultation information and prescription records may be securely stored and accessed by authorised clinic personnel as required for your care.

Prescription Fulfilment

If your doctor issues a prescription following assessment, your eScript is sent directly to you. You may use a pharmacy of your choice, subject to its dispensing requirements and availability. Medication is paid for separately at that pharmacy’s price. Elite TRT does not add a markup to medication costs. Prescribing, quantity and review intervals remain the treating doctor’s clinical decision. A consultation does not guarantee a prescription.

By completing this form, you confirm that the information you have provided is accurate and complete and that you understand the potential benefits, risks and requirements associated with medical assessment and treatment.

I confirm that I have read and understood the Men’s Sexual Health Patient Consent and Disclosure Agreement, including the potential benefits and risks of treatment, telehealth consent, data handling and prescription fulfilment.

Patient Consent and Disclosure Agreement(Required)

Men’s Hair Loss - Patient Consent and Disclosure Agreement

Purpose of Hair Loss Treatment

Where clinically indicated, treatment may be prescribed to manage male hair loss. The prescribing doctor will assess the pattern and history of your hair loss, previous treatments, medical history and other relevant factors before determining whether treatment is appropriate.

Individual response to treatment varies and hair regrowth, prevention of further hair loss or any particular outcome cannot be guaranteed.

Potential Benefits and Risks

Benefits: Treatment may assist with the management of certain forms of male hair loss. Potential benefits, risks, treatment options and alternatives will be discussed with the prescribing doctor.

Risks: Side effects vary according to the medication prescribed and may include scalp irritation, changes in blood pressure, dizziness, changes in sexual function, changes in mood and other adverse effects. Some treatments may not be appropriate for particular types of hair loss or medical conditions.

The doctor may recommend further investigation or referral where the pattern of hair loss suggests another underlying cause.

Ongoing Care

Treatment response and tolerability may be reviewed periodically. You should advise the clinic of any new symptoms, adverse effects, medication changes or significant changes in your health.

Telehealth Consent

You consent to receiving healthcare services via telehealth and understand the limitations of remote consultations and the requirement for suitable technology and a private environment.

Data Handling and Confidentiality

EliteTRT handles personal and health information in accordance with applicable Australian privacy requirements. Treatment records, consultation information and prescription records may be securely stored and accessed by authorised clinic personnel as required for your care.

Prescription Fulfilment

If your doctor issues a prescription following assessment, your eScript is sent directly to you. You may use a pharmacy of your choice, subject to its dispensing requirements and availability. Medication is paid for separately at that pharmacy’s price. Elite TRT does not add a markup to medication costs. Prescribing, quantity and review intervals remain the treating doctor’s clinical decision. A consultation does not guarantee a prescription.

By completing this form, you confirm that the information you have provided is accurate and complete and that you understand the potential benefits, risks and requirements associated with medical assessment and treatment.

I confirm that I have read and understood the Men’s Hair Loss Patient Consent and Disclosure Agreement, including the potential benefits and risks of treatment, telehealth consent, data handling and prescription fulfilment.

Patient Consent and Disclosure Agreement(Required)

Weight Management - Patient Consent and Disclosure Agreement

Purpose of Weight Management Treatment

Weight management care involves medical assessment of factors relevant to body weight, appetite, nutrition, lifestyle and overall health. Where clinically appropriate, the prescribing doctor may recommend lifestyle measures, medical treatment or other management options.

Treatment suitability is determined individually. Weight loss and other treatment outcomes vary between patients and cannot be guaranteed.

Potential Benefits and Risks

Benefits: Treatment may assist with medically supervised weight management where clinically appropriate. Potential benefits, risks, treatment options and alternatives will be discussed with the prescribing doctor.

Risks: Side effects depend on the treatment prescribed and may include nausea, vomiting, diarrhoea, constipation, abdominal discomfort, reduced appetite and other adverse effects. Some treatments may carry additional risks or may not be suitable for people with particular medical conditions, medication use or medical histories.

You must provide accurate information regarding your medical history, previous weight-management treatment, medications, allergies and any relevant gastrointestinal, pancreatic, gallbladder, thyroid or eating-related conditions.

Ongoing Care

Treatment response, tolerability and ongoing suitability may be reviewed periodically. The prescribing doctor may recommend additional investigations, pathology testing or referral to another healthcare professional where clinically appropriate.

Telehealth Consent

You consent to receiving healthcare services via telehealth and understand the limitations of remote consultations and the requirement for suitable technology and a private environment.

Data Handling and Confidentiality

EliteTRT handles personal and health information in accordance with applicable Australian privacy requirements. Treatment records, consultation information and prescription records may be securely stored and accessed by authorised clinic personnel as required for your care.

Prescription Fulfilment

If your doctor issues a prescription following assessment, your eScript is sent directly to you. You may use a pharmacy of your choice, subject to its dispensing requirements and availability. Medication is paid for separately at that pharmacy’s price. Elite TRT does not add a markup to medication costs. Prescribing, quantity and review intervals remain the treating doctor’s clinical decision. A consultation does not guarantee a prescription.

By completing this form, you confirm that the information you have provided is accurate and complete and that you understand the potential benefits, risks and requirements associated with medical assessment and treatment.

I confirm that I have read and understood the Weight Management Patient Consent and Disclosure Agreement, including the potential benefits and risks of treatment, telehealth consent, data handling and prescription fulfilment.

• Testosterone Replacement Therapy (TRT):
For the medical assessment and management of male hypogonadism. Recent blood tests are required before a TRT assessment can be completed.

• Men’s Sexual Health:
For the assessment and management of erectile dysfunction (ED) and premature ejaculation (PE). Initial blood tests are not routinely required.

• Men’s Hair Loss:
For the assessment and management of male pattern hair loss. Initial blood tests are not routinely required.

• Weight Management:
For the medical assessment of weight management for men. Initial blood tests are not routinely required.

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.

Which service are you interested in?(Required)

Testosterone Replacement Therapy (TRT)

Men’s Sexual Health

Men’s Hair Loss

Weight Management

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)

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)

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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.

Recent unintentional weight loss(Required)

Yes

Have you unintentionally lost more than 6 kg in the past 3 months?

Loss of control over eating(Required)

Yes

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

Vomiting after eating(Required)

Yes

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

Concerns about body size or shape(Required)

Yes

Do you often feel unhappy with your body size or shape, even when others tell you that you are at a healthy weight?

Preoccupation with food or weight(Required)

Yes

Do thoughts about food, eating, weight or your body take up a significant amount of your time or attention?

Appetite and cravings(Required)

Yes

Do you experience frequent cravings or difficulty controlling your appetite?

Emotional eating(Required)

Yes

Do you experience emotional eating or eating in response to stress, mood or boredom?

Joint pain or mobility(Required)

Yes

Do you experience joint pain or reduced mobility associated with your weight?

Fatigue or low energy(Required)

Yes

Do you experience persistent fatigue or low energy?

Daytime sleepiness or poor sleep(Required)

Yes

Do you experience daytime sleepiness or poor sleep quality?

Previous weight-loss attempts(Required)

Yes

Have you previously attempted to lose weight through diet, exercise or lifestyle changes?

Please provide brief details of your previous weight-loss attempts.(Required)

Previous weight-management medication(Required)

Yes

Have you previously used prescription medication for weight management?

Which medication did you use, for how long, and did you experience any side effects?(Required)

Bariatric surgery or weight-loss procedures(Required)

Yes

Have you previously undergone bariatric surgery or another weight-loss procedure?

Please provide details, including the type of procedure and approximately when it was performed.(Required)

Eating disorder history(Required)

Yes

Have you ever been diagnosed with or treated for an eating disorder?

Pancreatitis or pancreatic disease(Required)

Yes

Have you ever been diagnosed with pancreatitis or another disease of the pancreas?

Gallstones or gallbladder disease(Required)

Yes

Have you ever been diagnosed with gallstones or gallbladder disease?

Gallbladder removal(Required)

Yes

Have you had your gallbladder surgically removed?

Thyroid Disease(Required)

Yes

Have you ever been diagnosed with a thyroid condition or thyroid disease?

Gastric emptying disorder(Required)

Yes

Have you ever been diagnosed with a gastric emptying disorder, such as gastroparesis?

Other gastrointestinal disease(Required)

Yes

Have you ever been diagnosed with another gastrointestinal disease or condition?

Further details(Required)

If you answered Yes to any of the above, please provide further details, including the condition, treatment received and current status.

Current medications and supplements(Required)

Do you currently take any prescription medications, over-the-counter medications or supplements? If yes, please provide details.

Medullary thyroid carcinoma/MEN2(Required)

Yes

Do you have a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN2)?

Previous reaction/allergy to weight-management medication(Required)

Yes

Have you ever had an allergic reaction to Mounjaro (tirzepatide), Ozempic (semaglutide), or another GLP-1/GIP medication?

Allergy/reaction details(Required)

Please provide details of the medication and the reaction you experienced.

Additional information(Required)

Is there anything else regarding your weight, appetite, eating patterns or previous weight-management treatment that you would like the doctor to know?

Duration of hair loss(Required)

Duration of hair loss How long have you noticed hair loss or thinning?

Location/pattern of hair loss(Required)

Frontal hairline/temples

Crown

Generalised thinning across the scalp

Patchy areas

Other

Where is your hair loss or thinning mainly occurring?

You selected other - please list the other area(s)(Required)

Rate of hair loss(Required)

Gradual - over several years

Moderate - over approximately 6-12 months

Rapid - over the past few months

Sudden onset

Unsure

How would you describe the rate at which your hair loss has occurred?

Previous hair transplant(Required)

Yes

Have you ever had a hair transplant?

Hair transplant details(Required)

Please provide brief details, including approximately when the procedure was performed.

Sudden or patchy hair loss(Required)

Yes

Have you experienced any sudden or patchy hair loss on your scalp, such as clearly defined, coin-sized areas?

Changes in hair texture(Required)

Yes

Have you noticed any changes in your hair texture, such as the hair becoming noticeably thinner, finer, more brittle or damaged?

Recent significant stressors(Required)

Yes

Have you experienced any significant stressors or major changes in your work, relationships or lifestyle recently?

Stressor details(Required)

Please provide brief details.

Eyebrow hair loss(Required)

Yes

Have you noticed any thinning or loss of hair from your eyebrows?

Previous hair-loss treatments(Required)

Yes

Have you previously used any treatments for hair loss, such as prescription or over-the-counter medication, topical treatments, PRP or specialised shampoos?

Previous treatment details(Required)

Please provide details of the treatment(s) used, how long you used them, the outcome, and any side effects you experienced.

Vitamin D deficiency(Required)

Yes

Have you ever been diagnosed with vitamin D deficiency?

Iron deficiency(Required)

Yes

Have you ever been diagnosed with iron deficiency?

Low blood pressure(Required)

Yes

Have you ever been diagnosed with low blood pressure (hypotension)?

Erectile dysfunction(Required)

Yes

Do you currently experience, or have you previously experienced, erectile dysfunction or difficulty achieving or maintaining an erection?

Scalp or skin conditions(Required)

Yes

Have you ever been diagnosed with eczema, dermatitis or another condition affecting your scalp or skin?

Other vitamin or nutritional deficiencies(Required)

Yes

Have you ever been diagnosed with another vitamin or nutritional deficiency?

Further details

If you answered Yes to any of the above, please provide further details.

Other medical history(Required)

Do you have any other past or current medical conditions? If yes, please provide details.

Current medications and supplements(Required)

Do you currently take any prescription medications, over-the-counter medications or supplements? If yes, please provide details.

Medication Allergies(Required)

Do you have any known medication or other allergies? If yes, please provide details.

Finasteride Allergy(Required)

Yes

Have you ever had an allergic reaction to finasteride?

Minoxidil Allergy(Required)

Yes

Have you ever had an allergic reaction to minoxidil?

Allergy/reaction details(Required)

If you selected yes to either allergy questions above - please provide details of the medication and the reaction you experienced.

Family history of hair loss(Required)

Yes

Unsure

Does hair loss or significant hair thinning affect anyone in your immediate family, such as your parents or siblings?

Family history details(Required)

Please provide brief details.

Treatment preference(Required)

Oral medication

Topical medication

No preference

Unsure - I would prefer to discuss the options with the doctor

If clinically appropriate and treatment options are available, would you prefer an oral or topical medication?

Additional information

Is there anything else regarding your hair loss, scalp health, previous treatments or medical history that you would like the doctor to know before your consultation?

Current Sexual health symptoms(Required)

Difficulty achieving an erection

Difficulty maintaining an erection

Premature ejaculation/ejaculating sooner than desired

Reduced libido/sexual desire

Other

What sexual health symptoms are you currently experiencing?

You selected Other(Required)

Please provide details.

Symptoms during masturbation and intercourse(Required)

During both

During masturbation only

During sexual activity with a partner only

Not applicable/unsure

Are these symptoms present during masturbation as well as sexual activity with a partner?

Duration of symptoms(Required)

How long have you been experiencing these symptoms?

Previous medication or treatment(Required)

Yes

Have you previously used any medications, therapies or other treatments for these symptoms?

Previous treatment details(Required)

Please provide details of what you have tried, how long you used it, whether it helped, and any side effects you experienced.

Difficulty achieving or maintaining erections(Required)

Yes

Do you experience difficulty achieving or maintaining an erection?

Erectile difficulty details(Required)

Please provide further details about the difficulties you experience.

Morning erections(Required)

Regularly

Occasionally

Rarely

Never

Unsure

Do you experience spontaneous erections upon waking?

Premature ejaculation(Required)

Yes

Do you experience premature ejaculation or ejaculation sooner than you would like?

Premature ejaculation details(Required)

Please provide further details, including approximately how soon ejaculation typically occurs and whether you feel you have difficulty controlling or delaying ejaculation.

Reduced libido(Required)

Yes

Have you noticed a reduction in your libido or sexual desire?

Frequency of symptoms(Required)

Every or almost every time

Most of the time

Approximately half the time

Occasionally

Rarely

How often do you experience the symptoms you have described?

Non-medication strategies(Required)

Yes

Have you tried any non-medication strategies or approaches that have improved your symptoms?

Details(Required)

Please provide details of what you have tried and whether it helped.

Low blood pressure(Required)

Yes

Have you ever been diagnosed with low blood pressure (hypotension)?

High blood pressure(Required)

Yes

Have you ever been diagnosed with high blood pressure (hypertension)?

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

Cardiovascular disease(Required)

Yes

Have you ever been diagnosed with cardiovascular disease, such as heart disease?

High cholesterol(Required)

Yes

Have you ever been diagnosed with high cholesterol?

Blood vessel disease(Required)

Yes

Have you ever been diagnosed with peripheral vascular disease or another blood vessel condition?

Mood disorders(Required)

Yes

Have you ever been diagnosed with or treated for anxiety, depression or another mood disorder?

Medical condition details(Required)

If you answered Yes to any of the above, please provide further details, including any current treatment.

Chest pain or dizziness(Required)

Yes

Do you experience chest pain or episodes of dizziness?

Details(Required)

Please provide further details.

Urinary symptoms(Required)

Yes

Do you experience any urinary symptoms, such as difficulty passing urine, incomplete bladder emptying, a weak urinary stream or other changes in urination?

Details(Required)

Please provide further details.

Current stress(Required)

Yes

Are you currently experiencing more stress than usual?

Stress details(Required)

Please provide brief details if you feel this may be relevant to your symptoms.

Other medical history(Required)

Do you have any other past or current medical conditions? If yes, please provide details.

Current medications and supplements(Required)

Do you currently take any prescription medications, over-the-counter medications or supplements? If yes, please provide details.

PDE5 inhibitor allergy(Required)

Yes

Have you ever had an allergic reaction to sildenafil (Viagra), tadalafil (Cialis), or another medication used to treat erectile dysfunction?

Details(Required)

Please provide details of the medication and reaction.

SSRI allergy(Required)

Yes

Have you ever had an allergic reaction to an SSRI antidepressant medication?

Details(Required)

Please provide details of the medication and reaction.

Additional information(Required)

Is there anything else regarding your sexual health, symptoms, previous treatment or medical history that you would like the doctor to know before your consultation?

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 - Number only)(Required)

Hip Circumference (in CM - Number only)(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 (SA)

Clinipath (WA)

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

If a prescription is issued after assessment, your eScript is sent directly to you. Which pharmacy arrangement would you prefer for dispensing?(Required)

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

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

Please select your pharmacy preference below. You may choose a pharmacy and pay its price for medication separately. Elite TRT does not add a medication markup.

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)

Your information.
A considered assessment.

In-depth Health History Questionnaire

Services

Your next step

Elite TRT

Your information.A considered assessment.

In-depth Health History Questionnaire

Services

Your next step

Elite TRT

Your information.
A considered assessment.