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ANTI-AGEING CONSULTATION FORM

Attention! All fields marked by an asterix (*) are mandatory

TITLEFIRST NAME *

SURNAME *

DATE OF BIRTH dd/mm/yyyy *

OCCUPATION *

MARITAL STATUS *

NUMBER OF CHILDREN *

HOME PHONE *

WORK PHONE

MOBILE *

WHAT IS THE BEST TIME FOR US TO CALL YOU? *

EMAIL *

MAILING ADDRESS

ADDRESS *

SUBURB *

STATE *

POSTCODE *

MEDICAL HISTORY

WHAT IS YOUR HEIGHT IN CENTIMETERS? *

WHAT IS YOUR WEIGHT IN KILOGRAMS? *
kgs

PLEASE LIST ANY MEDICAL PROBLEMS *
e.g. Cancer or family history, depression, diabetes, headaches etc

PLEASE LIST ANY SURGERY YOU HAVE HAD *

PLEASE LIST MEDICATIONS THAT YOU ARE TAKING *

PLEASE LIST NON-MEDICAL, HEALTH FOOD SUPPLEMENTS THAT YOU HAVE TAKING *
e.g protein powders, herbal, tribulus

HAVE YOU FOUND THESE SUPPLEMENTS USEFUL? *
YES NO

DO YOU SUFFER FROM ANY ALLERGIES TO MEDICATIONS,
FOODS PRODUCTS ETC *
YES NO

DO YOU SMOKE, IF SO HOW MANY CIGARETTES EACH DAY *

YES

NO

cigarettes

ARE YOU A PROFESSIONAL ATHLETE? *
YES NO

DO YOU EXERCISE, IF SO HOW MUCH AND FOR HOW LONG? *

DO YOU HAVE A PERSONAL TRAINER WHO HAS ASSISTED YOU WITH YOUR EXERCISE PROGRAM AND DIET? *
YES NO

WHAT SPECIFIC CONCERNS OR FEARS DO YOU HAVE?
PLEASE STATE. *

All emails are treated as strictly confidential.

YOUR ENQUIRY *

This gives you the opportunity to discuss why your coming to see Dr Colagrande and how you are feeling, for example:

“I have noticed over the past few years that my energy levels have gone down and I'm looking at some improvement in quality of life.”

SURGICAL HISTORY

Do you experience any of the following? (Please tick)

Low energy levels
Reduced sexual activity/desire
Difficulty getting out of bed
Getting sick more frequently
Mood irritability
Persistent muscular injury
Persistent fat gain
Diminished exercise capacity
High blood pressure
Persistent joint aches and pains
Difficulty attaining an erection
Difficulty sustaining an erection
Hot flushes and sweats
Diminished physical or work performance
Decreased motivation & self confidence
Poor concentration & memory
Easily fatigued
Dry skin/hair
Decreased sleep
Prolonged joint/muscle pain
Lack enthusiasm for work/life
Loose skin
Poor memory
Poor muscle tone

HOW LONG HAVE YOU BEEN EXPERIENCING THESE SYMPTOMS?

PLEASE SUPPLY ANY ADDITIONAL IMPORTANT INFORMATION RELATING TO YOUR SYMPTOMS ABOVE:

WHAT ALTERNATIVES HAVE YOU TRIED TO HELP WITH THE ABOVE SYMPTOMS
e.g exercise, diet, supplements?

ARE THERE ANY SPECIFIC TREATMENTS OR PRODUCTS THAT YOU WOULD LIKE FURTHER INFORMATION ABOUT?
YES NO

FEEDBACK

We value your feedback and comments. In order for us to improve our services could you please complete the information below.

How did you hear about us?

Do you have any suggestions that you feel could improve our services?

SUBMIT YOUR INFORMATION

This online consultation does not take the place of a formal consultation with Dr. Colagrande, during which a complete assessment of your needs and an in depth discussion of the procedure and possible risks will be undertaken.

DISCLAMER: I confirm that the above health history is accurate and complete. I understand that withholding any medical information will be detrimental to my health and safety.

Please type in your email address to confirm the above information is accurate and complete: *