WHAT ARE YOUR HEALTH GOALS?
Which areas are you looking to improve?
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Weight Loss
Sexual Health
Hair Loss
Mood & Sleep
Gut Health
Muscle Development / Testosterone Optimisation
Erectile Dysfunction
Anti-Aging
Injury Repair & Recovery
Cognitive Performance Repair
YOUR DETAILS
First Name
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Last Name
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Email
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Phone
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Date of birth
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Sex
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Male
Female
Are you Pregnant or Breastfeeding?
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Yes
No
Do you confirm that you are not a professional athlete?
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Yes
No
Now let's answer some questions about your preferred health goals to optimise your treatment plan.
Weight Loss
Have you ever been diagnosed with type 1 diabetes?
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Yes
No
Have you ever had any of the following health conditions?
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Pancreatitis
Severe Renal Impairment
Diabetic Retinopathy
History of eating disorder
Severe gastroparesis
Active cancer
None of the above
Have you ever had gallstones or your gallbladder removed?
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Yes
No
Has anyone in your close family (parent, sibling, child) had medullary thyroid cancer or MEN2?
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Yes
No
Unsure
Are you currently taking insulin or sulfonylureas (diabetes tablets)?
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Yes — insulin
Yes — sulfonylureas
Yes — both
No / Neither
Sexual Health
What best describes your main concern?
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Low libido
Erectile difficulties
Orgasm difficulties
Pain/discomfort
Other
Do you experience any of the following?
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Reduced libido
Reduced morning erections
Fatigue
Loss of muscle mass
Have you been pregnant or given birth in the last 12 months?
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Yes
No
Are your menstrual cycles currently:
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Regular
Irregular
Stopped/Menopausal
Not applicable
Do you currently use any hormonal contraception or HRT?
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Yes — combined pill / patch / ring
Yes — progesterone-only
Yes — HRT
No
Have you previously used medication for sexual performance or libido?
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Yes worked well
Yes side effects
Yes didn't work
No
Do you notice reduced morning erections compared to the past?
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Yes
No
Erectile Dysfunction
Which best describes your erectile issue?
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Difficulty achieving erection
Not as hard as I'd like
Both
Not applicable
Do you wake up with morning erections?
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Often
Sometimes
Rarely
Never
Have you had any of the following in the past 6 months?
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Heart attack
Stroke
Unstable angina
Severe heart failure
None of the above
Do you currently take or have any of the following?
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Nitrate medications (Gtn, Isosorbide)
Alpha-blockers
Severe low blood pressure
Retinities pigmentosa
None of the above
Have you ever been advised to avoid sexual activity due to heart conditions?
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Yes
No
Unsure
Hair Loss
Which best describes your hair loss?
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Receding hairline
Thinning on crown
General thinning all over
Patchy areas of loss
Other
Have you ever used any treatments for hair loss?
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Minoxidil topical
Minoxidil oral
Finasteride / Dutasteride
Hair transplant / PRP
Over-the-counter shampoos / supplements
None
Have you EVER been diagnosed with prostate enlargement, elevated PSA, or prostate cancer?
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Yes
No
Not applicable
Did you experience side effects from any hair loss treatment?
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Yes
No
Haven't used treatments
Do you currently have any scalp issues?
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Itching
Flaking / dandruff
Redness / soreness
None of the above
MOOD & SLEEP
Do you have difficulty:
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Getting to sleep
Staying asleep
Both
No trouble sleeping
How many hours of sleep do you usually get per night?
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Less than 5
5–6
7–8
More than 8
Do you wake up feeling refreshed and ready for the day?
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Less than 5
5–6
7–8
More than 8
Have you EVER been diagnosed with any of the following?
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Depression
Anxiety disorder
Bipolar disorder
Psychosis or schizophrenia
ADHD
None of the above
In the past 12 months, have you experienced any of the following?
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Hospitalisation for mental health
Suicidal thoughts
Severe mood swings or manic episodes
History of self-harm
History of psychotic episode
None of the above
Are you currently taking or using any of the following?
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Antidepressants
Mood stabilisers
Antipsychotics
ADHD stimulant medication
Recreational drugs (regular use)
Excess alcohol use
None of the above
Have you been diagnosed with any of the following sleep conditions?
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Obstructive sleep apnoea
Severe chronic insomnia
None of the above
REPAIR & RECOVERY (INJURY & PAIN)
Are you currently dealing with a specific injury or painful area?
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Yes – one area
Yes – multiple areas
No
Which best describes the injury?
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Acute injury (recent tear/sprain)
Chronic tendon/ligament issue
Joint pain / arthritis
Post-surgical recovery
Not sure
Have you had surgery in this area in the past 6 months?
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Yes
No
Have you been diagnosed with any autoimmune or inflammatory conditions?
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Rheumatoid arthritis
Lupus
Psoriasis
Inflammatory bowel disease
None of the above
Do you currently have any of the following?
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Active infection
Open wound that is infected
Currently on immunosuppressant medication
Currently on blood thinning medication (e.g., warfarin, apixaban)
Active Cancer
None of the Above
GUT HEALTH
Which gut symptoms do you experience? (Select all that apply)
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Bloating / gas
Constipation
Diarrhoea
Abdominal pain or cramps
Reflux or heartburn
None
How often do you experience these symptoms?
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Less than once per week
1–3 days per week
Most days
Every day
Do you experience any of the following significant gut symptoms?
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Ongoing severe abdominal pain
Chronic diarrhoea
Chronic constipation
Unexplained weight loss
Blood in stool
None of the above
Have you been diagnosed with any of the following gastrointestinal conditions?
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Crohn’s disease
Ulcerative colitis
Coeliac disease
Chronic liver disease
Gastric or duodenal ulcer
None of the above
ANTI-AGING & LONGEVITY
What are your main anti-aging concerns? (Select all that apply)
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Energy and vitality
Skin quality / wrinkles
Recovery from exercise or stress
Cognitive performance
Body composition
Sleep
Longevity
How would you rate your overall energy during the day?
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Very low
Low
Moderate
High
Do you notice changes in your skin?
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Fine lines / wrinkles
Loss of elasticity
Pigmentation or sun damage
None of the above
What is your top priority to change in the next 6 to 12 months?
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Feel younger/more energetic
Look younger/improve skin
Move better/less stiffness
Protect long-term health
Have you EVER been diagnosed with any of the following serious medical conditions?
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Severe liver disease
Severe kidney disease
Heart failure
Stroke
Diabetes
Blood clot (DVT / pulmonary embolism)
Rheumatoid arthritis
Multiple sclerosis
None of the above
Are you currently using any of the following?
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Growth hormone
Testosterone therapy
Peptides
High-dose NAD therapy
Immunosuppresive medications
None of the above
COGNITIVE PERFORMANCE & REPAIR
Which cognitive challenges are you currently experiencing?
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Brain fog
poor focus
memory difficulties
low mental energy
reduced motivation
Have you ever had any of the following?
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Concussion/head injury
seizure disorder
stroke
neurological condition
none of the above
Have you ever been assessed or treated for ADHD or other learning conditions?
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Yes – diagnosed
Yes – suspected but not diagnosed
No
Do you currently use any of the following regularly?
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Alcohol
Recreational Stimulants
Cannabis
None of the Above
Have you had recent blood tests (e.g. B12, iron, thyroid) for fatigue or brain fog?
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Yes - normal
Yes - abnormal
No - not sure
What would you most like to improve?
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Focus and productivity
Memory
Mental clarity
Overall brain health long-term
MUSCLE DEVELOPMENT
What is your primary performance goal?
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Increased muscle size
Increase strength
Increase performance
Improve recovery
Improve body composition
Have you ever been diagnosed with any of the following? (Please select all that apply)
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Severe liver disease
Severe kidney disease
Heart disease
High Blood Pressure
None of the Above
Have you previously used performance-enhancing substances?
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Anabolic steroids
Testosterone Therapy
Growth Hormone
Peptides
None of the Above
Are you experiencing any of the following?
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Difficulty gaining muscle
Slow recovery from training
Declining strength
None of the Above
Have you been diagnosed with any of the following?
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Enlarged Heart
Elevated Haematocrit
Blood Clot
None of the Above
Are you planning to have kids within the next 12–18 months?
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Yes
No
Unsure
Fertility Consideration
Testosterone Replacement Therapy (TRT) may significantly reduce sperm production and impact fertility. If you’re considering having children in the near future, your doctor will discuss alternative treatment options and fertility-preservation strategies during your consultation.
Would you like to be considered for Testosterone Therapy and/or Growth Hormone Therapy?
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Yes
No
Unsure
What is your primary reason for hormone optimisation?
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Energy
Body composition
Recovery
Libido
Mood / cognition
Blood test results will be required for us to assess whether you are eligible for our Testosterone Therapy program. This ensures we can create a safe and effective treatment plan optimised for you.
Have you had testosterone bloods done in the last 12 months?
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Yes – I have results
Yes – I don’t have the results handy
No – I need to purchase a blood test
Don't have your recent Blood Test results handy? No worries!
You will receive an email from us, where you can upload and attach your results.
Upload your Blood Test results
*
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
We have sent you an SMS and an email with a link to purchase your comprehensive male blood test referral. To ensure your treatment plan is not delayed, get a morning fasted blood test completed as soon as possible.
GENERAL MEDICAL HISTORY
Height (cm)
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Weight (kg)
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Have you ever been diagnosed with any of the following? (Select all that apply)
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Heart attack
Stroke
Unstable angina
Heart failure
Active cancer (or within 5 years)
Severe high blood pressure
Severe liver disease
Blood clot (DVT/PE)
Severe kidney disease
None of the above
Are you currently taking any prescription medications?
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Yes
No
Provide details here
*
Do you have any known drug or food allergies?
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Yes
No
Provide more details
*
Do you currently smoke or vape?
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Yes - Daily
Yes - Occasionally
No
Do you drink alcohol?
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1-7 standard drinks/week
8-14 drinks/week
15+ standard drinks/week
No
Have you been diagnosed with cancer in the past 5 years?
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Yes
No
Please provide details here
*
Have you ever taken peptides or hormone-based therapies before?
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Yes
No
Provide all the details here
*
MEDICARE DETAILS
Medicare Number
*
Address
*
Street Address
*
City
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State
Country
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
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Seychelles
Sierra Leone
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Slovenia
Solomon Islands
Somalia
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South Georgia and the South Sandwich Islands
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Sudan
Suriname
Svalbard and Jan Mayen
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Switzerland
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Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Postal Code
*
Is the above address your delivery address?
*
Yes
No
Please provide your delivery address.
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MEDICAL CONSENT
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I confirm the information provided is true and correct. I understand this is not a diagnosis and a clinician will review my responses before prescribing any treatment. I consent to being contacted by TIDES Health via phone, SMS or email regarding my consult and treatment options, as well as educational & promotional information.
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