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1.1 – Personal Details
Title
Select
Mr.
Mrs.
Ms.
Dr.
Prof.
Preferred Name
First Name
Middle Name
Last Name
Gender
Select
Female
Male
Other
Date of Birth
1.2 – Contact Details
Email
Phone Number
Address
1.3 – Medicare Details
I don't have Medicare
Medicare Card No
Individual Reference No
Expiry Month / Year
2.1 – MEDICAL ELIGIBILITY
Are you 30 years old or older?
Yes
No
Men's Health - Do you have any of the following medical conditions? (Select all that apply)
History of prostate cancer
History of any cancer
Cardiovascular disease
Diabetes Mellitus
Liver and/or kidney disease
Haemochromatosis
Glaucoma
Sleep apnoea
Hypertension
Hypothyroidism
Any endocrine or genetic conditions
None of the above
Do you have any other current or past medical conditions not listed above?
Yes
No
Please provide more information:
Have you previously been on, or are you currently on, testosterone replacement therapy?
Yes – within the past month
Yes – approximately 3 months ago
Yes – approximately 6 months ago
Yes – 1 year ago or more
No
Where do you currently go for your TRT? (Please include the name of the medical centre, specialist, or GP)
Are you currently taking, or have you recently taken, any prescription medications?
Yes
No
Please provide more information:
Are you currently using anabolic steroids?
Yes
No
3.1 – ANDROGEN DEFICIENCY IN AGING MALES (ADAM) SCREENER
Major Criteria
Do you have decreased libido (sex drive)?
Yes
No
Do you have a decrease in erection strength?
Yes
No
Minor Criteria
Do you have a decrease in strength and/or endurance?
Yes
No
Have you lost weight?
Yes
No
Have you noticed a decreased "enjoyment of life"?
Yes
No
Are you sad and/or grumpy?
Yes
No
Do you have a lack of energy?
Yes
No
Have you noticed a recent deterioration in your ability to play sports?
Yes
No
Are you falling asleep after dinner?
Yes
No
Has there been a recent deterioration in your work performance?
Yes
No
4.1 – Confirmation
Confirm you are ready to finalise and submit this form to your practitioner.
*
Yes, I've checked that I've completed the form and saved my answers.
Submit