Doctor Questionnaire - UHD Bio Health

Full Name *

Phone regular? are

Date of Birth *

Gender *

Male
Female

Height (cm) *

Weight (kg) *

Phone Number *

Email Address *

What are your primary goals? *

Fat loss
Muscle gain
Performance
Recovery
Longevity / health optimisation
Other

If other, please specify

What outcome are you hoping to achieve? *

Have you previously used any of the following? *

GLP-1 medications
Peptide therapies
Hormone-related treatments
No prior use

If yes, please specify what you have used and when

Current weight *

Highest weight in the past 5 years *

Lowest adult weight *

Have you attempted weight loss before? *

If Yes what methods have you tried?

Do you have any diagnosed medical conditions? *

Have you ever been diagnosed with any of the following? *

High blood pressure
Heart disease
Diabetes
Thyroid disorder
Liver disease
Kidney disease
Cancer
Other
None

If Other please specify

Are you currently under the care of a doctor or specialist? *

Please provide details

Do you have a history of any of the following? *

Heart attack
Stroke
Blood clots
Arrhythmia
None

Do you currently experience any of the following? *

Chest pain
Shortness of breath
Dizziness
Fainting
None

Do you monitor your blood pressure? *

What is your average reading?

Have you been diagnosed with any of the following? *

Insulin resistance
Type 2 diabetes
Low testosterone
PCOS
None

Have you had hormone blood work done previously? *

Are you currently taking any prescription medications? *

List all medications and dosages

Are you currently taking any of the following?

Blood pressure medication
Diabetes medication
Thyroid medication
Antidepressants / psychiatric medication
None

Are you currently taking any supplements? *

Please list them *

Do you have any allergies to medications? *

Please list them

Have you ever had a negative reaction to any medication or treatment? *

Please explain

Do you experience any of the following? *

Nausea
Reflux / heartburn
Constipation
IBS or digestive issues
None

How many days per week do you train? *

What type of training do you do? *

How would you rate your diet? *

Poor
Average
Good
Very good

How many hours of sleep do you get per night? *

Do you feel well rested on waking? *

How would you rate your stress levels? *

Low
Moderate
High

Do you smoke? *

Do you consume alcohol? *

How often?

Do you experience any of the following? *

Low energy
Poor recovery
Difficulty losing fat
Difficulty gaining muscle
Brain fog
Poor sleep
Low libido
Other
None

Please specify

Are your menstrual cycles regular?

Are you currently using contraception?

Have you had recent blood tests? *

Upload blood test results

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Upload any additional supporting documents

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Are you currently pregnant or breastfeeding? *

Yes
No
Not applicable

Have you had cancer in the past 5 years or are you currently undergoing treatment? *

How consistent are you with routines? *

Not consistent
Somewhat consistent
Very consistent

What has stopped you achieving your goals in the past? *

Medicare Card Number *

Individual Reference Number (IRN) *

Expiry Date *

Consent *

I confirm that the information provided is accurate and complete to the best of my knowledge. I understand this information will be used by a licensed doctor to assess my suitability for treatment.

Additional Consent & Acknowledgement *

I consent to UHD BioHealth coordinating my care, including communication with the prescribing doctor and management of prescriptions and pharmacy processes on my behalf.

I understand that UHD BioHealth does not provide medical advice or prescribe medications, and all prescribing decisions are made independently by a licensed Australian doctor.

I acknowledge that all treatments are subject to medical assessment and approval, and are not guaranteed.

I consent to my information being shared with relevant healthcare providers, including doctors and pharmacies, for the purpose of assessment, prescribing, and dispensing.

I understand that additional requirements, including pathology testing or further consultation, may be required before treatment can proceed.

I acknowledge that payment does not guarantee treatment approval and is held pending medical review. If treatment is not approved, I will be offered an alternative or a refund.

Signature *

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