First Name
Surname
Email address
Mobile Number
Date of birth
Address
Street address *
City
StatePlease selectACTNSWNTQLDSATASVICWA
Postcode
Are you an existing Hydralyfe customer? YesNo
I am not a professional athlete.
Gender Identity MaleFemaleNon-BinaryGender Diverse
Are you over 18? YesNo
Are you of Aboriginal and/or Torres Strait Islander origin? YesNoPrefer not to say.
Occupation?
How would you rate your overall health?ExcellentGoodAveragePoorVery badUnsure
Do you have any known allergies? YesNo
My Height in Centimeters is:
My current weight in kilograms is:
What is your current waist size in inches?
How did you hear about us
What are your treatment goals? Improve My AppearanceWeight loss / Fat metabolismLibido / Sexual healthAnti aging / skinCellular healthMuscle health and developmentCognitive performance / FocusReduce PainImprove SleepImprove MoodImmunityHave More EnergyImprove FunctioningBecome HealthierOther
Have you had surgery in the last 12 months YesNo
Do you have a regular General Practitioner?YesNo
Last general medical check up
Are you seeing a specialist for any conditions? YesNo
Covid VaccinatedYesNoRather not say
My issue affects my daily routine and/or affects my ability to work.NeverRarelySometimesFrequentlyAlwaysI don't have a specific issue I need to address.
Please provide additional information that may be useful to the practitioner
How would you rate your mood?HappyGrumpySadDon't know.Other
Is there anything you'd like to add about your mood?
Would you be interested in us including the option for transformational coaching, energy alignment or hypnosis in your plan? Yes, I'm curiousYes, I'd like to know more about how hypnotherapy may help.Yes, I think I need some help with my mindset and how I feel about myself.No, I'm not into any of the above
How do you rate your current diet?Very HealthyHeathy-ishNot idealVery BadUnsure
Are you currently on a diet?YesNoUnsure
Would you like us to include the option for a nutrition or naturopath plan in your program quote?Yes please I'm curious what that would cost and how it may benefitNo I know exactly what I should be eating
Do you smoke? YesNo
Have you or anyone in your immediate family ever had diabetes? YesPrediabetesNo
Have you or anyone in your immediate family had heart disease? YesNo
Have you ever been diagnosed with cancer? YesNo
Has any of your immediate family been diagnosed with cancer? * YesNo
Are you currently taking any of the following medications?Heart medicationAnti-inflammatory medicationInsulin or anti diabetic medicationBlood pressure medicationFluid reducing or diuretics.Anti-depressant or anti-anxiety medicationLithiumNo, I am not taking any of the aboveHeart medicationAnti-inflammatory medicationInsulin or anti diabetic medicationBlood pressure medicationFluid reducing or diuretics.Anti-depressant or anti-anxiety medicationLithiumNo, I am not taking any of the above
Are you taking any medications or supplements other than the above? (prescribed or unprescribed) YesNo
Have you used peptides before? YesNo
Have you used anabolic steroids or hormone replacement therapies before?YesNo
Please select any and all that apply to you.I drink 3 standard drinks per day or more than 15 standard drinks per week.I use cannabis and/or recreational drugs.I'm frequently under stress.I sleep less than 6 hours a night.None of the above apply to me.
Please provide relevant information for any/all selections
In general, how do you rate your physical fitness. ExcellentGoodOkBelow AveragePoorVery Poor
How much moderate physical activity do you do each day?Less than an hour1-3 hours4-6 hours7 or more hours
What is your last known blood pressure?
What is your current resting heart rate?
Have you or anyone in your immediate family ever had issues with the below? Gallbladder problems including gallstones.Pancreas issues or pancreatitis.Issues with liver function.Kidney function or kidney disease.Low blood sugar (hypoglycemia)Diabetic including diabetic eye disease.Suicidal thoughts or history of severe mood disorderThyroid issues or tumorsHigh Blood pressure (Hypertension)Sleep apnoeaCancerGastrointestinal issuesHeart disease or abnormal heart rhythmHormone or sexual dysfunctionHigh cholesterolOsteoarthritis or joint painHigh blood sugarUrinary problems (e.g., incontinence)EpilepsyStrokeNone of the above
Would you please tell us a little more information about the above the above selection.
Do you have any current or past medical conditions not mentioned above? YesNo
Do you suffer from any joint problems?YesNo
Do you suffer from any injuries or pain?YesNo
Are you open to using tablets and/or injections? I am open to both tablets and injections.I am open to tablets only.I am open to injections.I am not open to either tablets or injections
Please upload your blood results.
First and middle name (if any) on identity
Surname on identity
Card number (driver's license number, proof of age card number) or passport number
Expiry date
Upload ID
Card number (driver's license number, proof of age card number) or passHow would you like your products delivered if you are issued a prescription?Please issue the prescription to the partner pharmacy and arrange a courier to deliver my product(s) to mePlease issue the prescription directly to me and I'll collect my products myself from the pharmacyPlease hold my prescription and provide the products at a future Hydralyfe appointmentI am in clinic and would like to take my prescription home with me
Delivery and/or service address if different to above
Authorised Collection Consent Form
TeleHealth Consent Form
I have read and fully understand the information in the Patient Consent Form and my answers are true and correct. Yes, I have read and fully understand the consent form and my answers are true and correctNo, I have not.
I confirm that I am over 18 years of age and not subject to any sporting or professional code where the treatments or medicines offered are prohibited.
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