Medical Questionnaire

  • Medical Questionnaire

  • Personal Details

  • Format: 0000 000 000.
  • Date of Birth
     - -
  • Sex
  • Is the above address your delivery address?
  • Do you confirm that you are over 18 years old?
  • Do you confirm that you are not a professional athlete?

  • Thank you for your response.

    Unfortunately, we cannot provide medical advice or prescribe medication to individuals under 18.

    If this information is not correct, you can go back.

  • Thank you for your response.

    Unfortunately, we cannot provide medical advice or prescribe medication to individuals who are professional athletes. 

    If this information is not correct, you can go back.

  • Health Goals

  • Which areas of your health are you looking to improve?

  • General Medical History

  • Vitals

  • Past & Current Medical Conditions

  • Have you ever been diagnosed with any of the following? (Select all that apply)
  • Have you been diagnosed with cancer in the past 5 years?

  • Symptoms & Lifestyle

  • Do you currently smoke or vape?
  • Do you drink alcohol?
  • How often do you exercise?
  • Which of the following have you experienced recently?

  • Medications, Allergies, Pregnancy

  • Are you currently taking any prescription medications?
  • Do you have any known drug or food allergies?
  • Do you currently take any of the following? (Select all that apply)
  • Have you ever taken peptides or hormone-based therapies before?*
  • Are you currently pregnant and/or breastfeeding?

  • Weight Loss

  • How long have you been struggling with your weight?
  • How would you describe your main challenge with weight?
  • How much weight would you ideally like to lose?
  • Have you tried any of the following in the last 12 months? (Select all that apply)
  • Have you ever been diagnosed with type 1 diabetes?
  • Have you ever had pancreatitis?
  • Have you ever had gallstones or your gallbladder removed?
  • Has anyone in your close family (parent, sibling, child) had medullary thyroid cancer or MEN2?
  • Are you currently taking insulin or sulfonylureas (diabetes tablets)?
  • How motivated do you feel to make lifestyle changes alongside any medication?

  • Sexual Health

  • What is your primary concern with sexual health?
  • How long has this been a concern?
  • How much is this impacting your relationships or quality of life?
  • Do you notice any of the following?
  • Have you been pregnant or given birth in the last 12 months?
  • Are your menstrual cycles currently:
  • Have you ever been diagnosed with any hormone-related conditions (e.g. PCOS, low testosterone, endometriosis)?
  • Do you currently use any hormonal contraception or HRT?
  • Have you previously used medication or therapy for sexual health concerns?
  • Do you notice reduced morning erections compared to the past?

  • Erectile Dysfunction

  • What symptoms are you experiencing? (Select all that apply)
  • How long have you been experiencing these issues?
  • Do you wake up with morning erections?
  • Rate your erection hardness
  • Do you have issues getting or staying hard when masturbating?
  • Have you experienced issues with premature ejaculation?
  • Do you experience chest pain or shortness of breath with exertion?
  • Have you every been advised to avoid sexual activity due to heart conditions?
  • Have you ever used medication for ED (e.g. Viagra, Cialis)?
  • Have you ever been told not to use ED medications because of heart disease or nitrate medication (e.g. GTN spray)?

  • Hair Loss

  • Which best describes your hair loss?
  • When did you first notice hair loss?
  • Does hair loss run in your family?
  • How quickly is your hair loss progressing?
  • Have you ever used any treatments for hair loss?
  • Did you experience side effects from any hair loss treatment?
  • How much body hair do you have?
  • Do you currently have any scalp issues?
  • Have you or a close family member had prostate issues (e.g. enlarged prostate, prostate cancer)?
  • How important is hair regrowth or preservation to you right now?

  • Mood & Sleep

  • Over the last month, how would you rate your overall mood?
  • Have you experienced any of the following? (Select all that apply)
  • Have you ever been diagnosed with depression, anxiety, bipolar, or another mental health condition?
  • Have you ever had psychological counselling or taken medication for mood or sleep?
  • Do you have difficulty:
  • How many hours of sleep do you usually get per night?
  • Do you wake feeling refreshed and ready for the day?
  • How would you rate your stress levels right now?
  • Have you ever had thoughts of self-harm or suicide?
  • What are you hoping to improve most?

  • Repair & Recovery (Injury/Pain)

  • Are you currently dealing with a specific injury or painful area?
  • How long has this issue been present?
  • What best describes the affected area?
  • How would you rate your current pain?
  • Have you had imaging or scans (X-ray, MRI, ultrasound) for this issue?
  • Have you had surgery on this area?
  • Does the injury limit your ability to work, exercise, or sleep?
  • Have you tried any of the following for this problem?
  • Do you have any inflammatory or autoimmune conditions (e.g. rheumatoid arthritis, lupus)?
  • What outcome are you most hoping for?

  • Gut Health

  • Which gut symptoms do you experience? (Select all that apply)
  • How often do you experience these symptoms?
  • How long have these gut issues been present?
  • Have you been diagnosed with any gut conditions?
  • Have you noticed any red-flag symptoms?
  • Have you had any recent gut investigations?
  • Do certain foods clearly trigger your symptoms?
  • How many standard drinks of alcohol do you have per week?
  • Do you regularly use over-the-counter remedies for gut symptoms (e.g. antacids, laxatives, anti-diarrhoeals)?
  • What’s your main goal for gut health?

  • Anti-Aging

  • What are your main anti-aging concerns? (Select all that apply)
  • How would you rate your overall energy during the day?
  • How would you rate your recovery after exercise or busy days?
  • Do you notice changes in your skin?
  • Have you been previsouly told that you are low in:
  • Do you take any anti-aging supplements or therapies currently?
  • Do you ever get numbness or tingling in your hands or experience carpel tunnel syndrome?
  • How is your sleep generally?
  • How would you rate your stress levels long-term (over the last year)?
  • What is your top priority to change in the next 6–12 months?

  • Cognitive Performance & Repair

  • Which issues are you experiencing? (Select all that apply)
  • How long have you noticed these difficulties?
  • How much do they affect your work / study / daily life?
  • Do symptoms change with sleep or stress?
  • Have you had any of the following?
  • Have you ever been assessed or treated for ADHD or other learning conditions?
  • Do you regularly use alcohol or recreational drugs?
  • Do you work night shifts or rotating rosters?
  • Have you had recent blood tests (e.g. B12, iron, thyroid) for fatigue or brain fog?
  • What would you most like to improve?

  • Muscle Development

  • How many times per week do you train?
  • What type of training do you mainly do?
  • What is your primary goal?
  • How would you rate your current strength compared to 12 months ago?
  • Have you ever been diagnosed with any heart, kidney, or liver conditions?
  • Have you used anabolic steroids, testosterone, or peptide therapies before?
  • Which symptoms are you experiencing?
  • How long has this been going on?
  • Are you planning to have kids within the next 12-18 months?

  • 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
  • What is your primary reason for hormone optimisation?
  • If testosterone therapy is recommneded, which best describes you?
  • Have you had testosterone bloods done in the last 12 months?

  • 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.

  • Upload your Blood Test results

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • 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.

  • Your Blood test results are required

  • Based on your answers, you may qualify for our Testosterone Therapy program

    Our doctors will need to review your blood test results to assess your current hormone levels and be able to offer you

    The TIDES Clinic & Bloody Good Tests have developed a comprehensive male blood test that gives our prescribers a full picture to be able to create the perfect treatment protocol for you.

  • Image field 212

  • How it works:

    1. Order your blood test
    We’ll send you a link via SMS and EMAIL to order your blood test.

    2. Get tested at a local lab
    Take your electronic referral to any of the collection centres.

    3. Results sent to TIDES Clinic
    Your results are sent directly to our doctors.

    4. Doctor consultation
    Review results and discuss your plan.

  • To ensure your treatment plan is not delayed, ensure that you purchase your blood test referral and get a morning fasted blood test completed as soon as possible.

  • Book your Consultation call back

    Select the best available time for our team to contact you directly, to discuss your previous answers and book in your appointment with our doctor.

  • Consent

  • Please provide your consent.
  • Should be Empty: