GENERAL INFO

First Name *

Last Name *

Phone *

Email *

ID No/Passport No *

Title *

Date of birth *

Home Address *

Street Address
Suburb
City
Postal Code

Work Address

Street Address
Suburb
City
Postal Code

Name of nearest Family or Friend in case of emergency *

Contact number of nearest Family or Friend in case of emergency *

Medical Aid *

Medical Aid Plan *

Dependent Code

Medical Aid No *

ACCOUNT HOLDER DETAILS

(IF DIFFERENT FROM PATIENT DETAILS)

First Name

Last Name

Initials

Phone

E-mail

Postal Address

ID No/Passport No

A. ALLERGIES/SENSITIVITIES

1. Allergies/Sensitivities *

2. Previous COVID Infection(s) *

3. COVID Vaccinations *

B. COVID

B. VITAL STATISTICS

4. Age *

3. Gender *

5. Height in cm *

6. Weight in kg *

7. Waist Circumference in cm or pants size *

C. BODY & FITNESS PARAMETERS

8. Cardiovascular Fitness *

9. Muscle Strength *

10. Flexibility *

D. HABITS & ADDICTIONS

11. Do you smoke cigarettes? *

12. Do you smoke pipe? *

13. Do you vape? *

14, Do you drink alcohol? *

15. If yes, *

What type of alcohol?
What is the dialy quantity?
What is the weekly quantity?
What is the monthly quantity?

16. Do you drink caffeine drinks? *

17. If yes, *

What type of caffeine drinks
What is the daily quantity?
What is the weekly quantity?
What is the monthly quantity?

E. WATER

18. Please select all the types of water you drink *

Municipal Tap Water

Filtered or Purified Tap Water

Bottled Mineral Water (Reverse Osmosis) (pH = 5-7)

Bottled Mineral Water (Reverse Osmosis + Minerals) (pH = 7.5 – 8.5)

Bottled Mineral Water (Natural Spring Water)

Borehole Water (unfiltered)

Borehole Water (Filtered)

19. Other Water (Name and type)

F. SLEEP AND EXERCISE

20. Which of the following describes your sleeping pattern the best? *

21. Which of the following best describes your movement pattern? *

Very sedentary. Mostly sitting or lying.

Walking only daily. No long walks, no brisk walks, no steps

A lot of walking per day, with long brisk walking and/stairs (5-15000 + steps)

Sports e.g. cycling, rugby, soccer, cricket, swimming (weekly)

Gym e.g. Cardiovas, Weights, Crossfit, Kick boxing (1-2x/week

Gym e.g. Cariovas, Weights, Crossfit, Kick boxing (3-4+/week)

H. BLOOD TESTS AND INVESTIGATION

23. Have you had any previous Pathology Tests performed (e.g. Blood, Urine, Stool, DNA etc)? *

24. If yes, please fill in the aproximate date

Ampath
Lancet
Pathcare
Toga
Other

e.g. 5 May 2025

25. Have you had any previous Special Medical Investigations, e.g. (X Rays, Ultrasounds, ECGs, CT + PET, Biopsies, Gastroscopies, Colonscopies, etc) *

26. If YES, which Investigations? *

27. Do you regularly do any of the following investigations? *

Annual Medicals

Screening

None

I. MEDICAL HISTORY

28. Do you suffer from any Chronic Medical Disorders or Current Health problems? *

29. Do you have a Family (Genetic/Inherited) history of any Medical Disorders? *

30. Have you had any Operations, Corrective Surgery or Accidents and Injuries? *

31. Are you currently taking any Pharmaceutical Medication? *

32. Are you currently taking any Food Supplements or Hormone Medication? *

J. SYMPTOMS

Do you experience any of the following symptoms?

33. Decreased Energy *

34. Chronic Fatigue *

35. Depressed Mood or Depression *

36. Erectile Dysfunction or Low Libido *

37. Weight gain (Visceral fat) *

38. Infections (Poor Immunity) *

39. Weak Bones or Fractures or Ligament/Muscle Strains *

40. Loss of Muscle Mass *

41. Brain Fog & Decreased Focus & Decreased Concentration *

42. Poor post exercise, or injury recovery *

43. Testes Shrinking *

44. Breasts enlarging (Gynaecomastia) *

45. Poor Sleep Quality *

46. Sleep Apnoea *

47. Other Symptoms *

L. TESTOSTERONE REPLACEMENT THERAPY

52. Do you or have you ever taken TRT (short acting or slow release testosterone replacement therapy or anabolic steroids)? *

53. If yes, please list all the products *

Product
Type (Oral/Injection)
Dosage
Frequency
Last Usage Date

e.g. Test E250, Injection, 1ml (250mg), 2× per week, 20 July 2025

54.

Product
Type (Oral/Injection)
Dosage
Frequescy
Last Usage Date

55.

Product
Type (Oral/Injection)
Dosage
Frequency
Last USage Date

HEALTH BENEFITS OF APPROPRIATE OPTIMAL PHYSIOLOGICAL TRT (TESTOSTERONE REPLACEMENT THERAPY)

Increased muscle mass and strength
Increased bone density and fewer fractures
Increased recovery from exercise
Decreased body and visceral fat
Increased libido and less erectile dysfunction
Enhanced sexual function
Increased energy and endurance
Increased recovery from injury
Immune system enhancement
Improved mood and less depression
Improved concentration and less brain fog
Increased red blood cell production
Improved cardiovascular health
Helps improve metabolic syndrome, obesity and diabetes type 2
Reduced cancer risk, especially prostate cancer
Improved weight gain, if underweight
Increased motivation
Increased overall health
Increased overall sense of well-being
Increased quality of life

POTENTIAL SIDE EFFECTS OF EXCESSIVE OR INAPPROPRIATE TESTOSTERONE SUPPLEMENTATION

Testicular shrinkage
Decreased sperm volume
Reduced fertility
Abnormally increased estrogen levels through testosterone conversion to estrogen
Gynaecomastia
Emotional lability
Liver damage
Kidney damage
Excess haemoglobin production
Excess red blood cell production
Hypothalmus – Pituitary – Adrenal Axis imbalance
Hypercoagulopathy

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T & C*By submitting this form, I agree to the Privacy Policy and Indemnity Form. I also consent to receiving communication from the company.