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DEAR LIFE - NEW CLIENT OPTIMISATION FORM

1. Personal Details

Full Name:

*

Date of Birth:

*

Phone:

*

Email:

*

Medicare Number / Expiry / Position:

2. Essential Medical Information

Have you been hospitalised or had surgery?

Yes

No

If yes, details:

Diagnosed medical conditions?

Yes

Untitled checkboxes field

No

If yes, list:

Medications (current):

Supplements:

Allergies:

3. Lifestyle Snapshot

Smoking

*

Smoking

Yes

No

Alcohol

*

Alcohol

Yes

No

Exercise

*

Exercise

Rarely

1–2×

3–4×

5+ weekly

Sleep quality

*

Sleep quality

Poor

Fair

Good

Excellent

4. Hormones & Symptoms

Used hormone therapy (TRT/BHRT/HRT)?

Yes

No

Women:

Period

Postmenopause

Menopause

Perimenopause

Key symptoms

Low energy

Weight gain

Brain fog

Low mood

Poor sleep

Libido

Hormone imbalance

Recovery issues

5. Your Priorities

Top 3 health goals:

1.

2.

3.

6. Pathology

Recent bloodwork?

Yes

No

If yes, upload/describe:

Size limit: 10 MB

Consent to pathology panel?

Yes

No

7. Consent

Untitled checkboxes field

I understand Dear Life provides education only.

I consent to share information with pathology partners.

I understand peptides may be experimental/off-label.

I confirm all information is true.

Signature

DEAR LIFE - NEW CLIENT OPTIMISATION FORM

1. Personal Details

Full Name:

Date of Birth:

Phone:

Email:

Medicare Number / Expiry / Position:

2. Essential Medical Information

Have you been hospitalised or had surgery?

If yes, details:

Diagnosed medical conditions?

If yes, list:

Medications (current):

Supplements:

Allergies:

3. Lifestyle Snapshot

Smoking

Alcohol

Exercise

Sleep quality

4. Hormones & Symptoms

Used hormone therapy (TRT/BHRT/HRT)?

Women:

Key symptoms

5. Your Priorities

Top 3 health goals:

1.

2.

3.

6. Pathology

Recent bloodwork?

If yes, upload/describe:

Consent to pathology panel?

7. Consent

Date: