How old are you?
*
Under 18
18–24
25–34
35–44
45–54
55–64
65+
What brings you to Benjamin Health today?
*
Hair loss or thinning
Erectile concerns
Weight management or metabolic health
Sleep and fatigue
Mood, stress, or anxiety
Preventive health and longevity
Unsure, I’d like guidance
Hair loss or thinning
When did you first notice hair thinning or shedding?
Within 6 months
6–12 months
1–3 years
Over 3 years
Which best describes your hair concern?
Receding hairline
Thinning crown
Diffuse thinning
Sudden shedding
Patchy hair loss
Any scalp symptoms?
Pain
Itching
Scaling
Scarring
None
Family history of hair loss?
Yes
No
Unsure
Have you tried any treatments?
None
Topical treatments
Oral treatments
Supplements
Other
Erectile concerns
How often are you experiencing difficulty?
Occasionally
Frequently
Most of the time
When did this begin?
Sudden onset
Gradual
Longstanding
Do you still experience morning erections?
Yes
No
Unsure
Do you take nitrates or medications for chest pain/angina?
Yes
No
Unsure
How would you rate stress levels currently?
Low
Moderate
High
Weight & Metabolic Health
What is your main goal?
Weight reduction
Metabolic health (blood sugar, cholesterol)
Energy and fatigue
Mobility
Unsure
How long have you been trying to address your weight?
Under 6 months
6–12 months
1–3 years
Over 3 years
Have you tried any of the following?
Diet changes
Exercise programs
Structured meal plans
Psychology support
Medication
None
Any history of
Pancreatitis
Severe gastrointestinal disease
Thyroid cancer (personal or family)
Gallbladder disease
None
Unsure
Your details
First Name
*
Last Name
*
Your Email Address
*
State/Territory
Select one...
NSW
VIC
QLD
WA
SA
TAS
ACT
NT
Height (cm)
Weight (kg)
Do you have a regular GP?
Select one...
Yes
No
Unsure
Your medical history
Do you have any of the following conditions?
*
Blood clots (DVT/PE)
Cancer (current or previous)
Diabetes or prediabetes
Fatty liver
High blood pressure
High cholesterol
Heart disease or angina
Liver disease
Migraine with aura
Sleep apnoea
Stroke or TIA
Thyroid disorder
None of the above
Prefer not to say
Do you smoke or vape nicotine?
Select one...
No
Yes, occasionally
Yes, daily
Prefer not to say
Do you drink alcohol?
Select one...
No
Yes, occasionally
Yes, most days
Prefer not to say
Are you taking any prescription medications?
Select one...
Yes
No
Prefer not to say
Please list your medications
Do you have any medication allergies?
Select one...
Yes
No
Please list your allergies
Have you had recent blood tests (within 12 months)?
Select one...
Yes
No
Unsure
Practicalities
How soon would you like to begin?
As soon as possible
In the next 2–3 weeks
Just researching
Do you prefer
Telehealth only
Telehealth with optional face-to-face if required
Unsure
Do you consent to Benjamin Health collecting this information for clinical triage?
*
Yes
No
Yes, I’d like to receive occasional emails from Benjamin Health about services, wellbeing updates and special offers.
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