BestU Telehealth: Online Wellness & Hormone Clinic Australia

New Patient Form

Gender

Male

Female

Weight (kg)

Height (cm)

Nationality

Date of Birth

Address

Home Address

Suburb

State

Postcode

Home Ph

Work Ph

Mobile

Prescription Delivery Address:

Prescription Delivery Address

Suburb

State

Postcode

Medicare Number

Expiry Date

Reference Number

Alcohol – how much alcohol do you drink per week on average?

In the past 12 months, have you had any weight loss

or weight gain __kg

What number do you believe reflects your current level of health?

On a scale of 0-10 (10 most energetic), how would you rate your energy level?

What time of day is it lowest?

What time of day is it highest?

Have you had

Cancer

Yes

Hypoglycaemia

Yes

Diabetes

Yes

Kidney Stones/Infections

Yes

Abnormal Liver Function Tests

Yes

High Blood Pressure

Yes

Palpitations or irregular heart beat

Yes

Seizures

Yes

Deep Vein Thrombosis DVT

Yes

Anaemia

Yes

Iron Deficiency

Yes

Agitation or anxiety

Yes

Depression

Yes

Muscle Pain

Yes

Consent & Privacy

I confirm that the information I have provided is true and accurate to the best of my knowledge. I consent to BestU Clinic collecting and using my personal and health information to assess my enquiry, contact me regarding my assessment, appointments, and healthcare, and coordinate my care where clinically appropriate. I understand my information will be handled in accordance with Australian privacy laws and that submitting this form does not guarantee treatment or establish a doctor-patient relationship.

Patient Signature

Print Name

Date

New Patient Form

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