How old are you?
*
Under 18
18–24
25–34
35–44
45–54
55–64
65+
What brings you to Benjamin Health today?
*
Perimenopause or menopause support
HRT assessment and management
Period changes or hormonal symptoms
Weight management or metabolic health
Hair loss or thinning
Sleep and fatigue
Mood, stress, or anxiety
Preventive health and longevity
Unsure, I’d like guidance
Are you currently pregnant, breastfeeding, or trying to conceive?
Pregnant
Breastfeeding
Trying to conceive
None of the above
Prefer not to say
Perimenopause, Menopause, HRT
Where do you feel you are in the transition?
Possibly perimenopause
Menopause (no periods for 12 months)
Surgical menopause (ovaries removed)
unsure
Are your periods changing?
Yes, heavier
Yes, lighter
Yes, more frequent
Yes, less frequent
No (or no longer having periods)
Not applicable
Which symptoms are you experiencing?
Hot flushes or night sweats
Sleep disruption
Mood changes (low mood, irritability)
Anxiety
Brain fog or concentration issues
Fatigue
Weight gain or body composition changes
Joint or muscle aches
Reduced libido
Vaginal dryness or discomfort
Pain with sex
Urinary urgency or recurrent UTIs
Palpitations
Headaches or migraines
Skin or hair changes
None of the above
How much are symptoms affecting your day-to-day life?
Mild
Moderate
Significant
Severe
What is your primary goal?
Reduce hot flushes and night sweats
Improve sleep
Improve mood and anxiety
Support energy and fatigue
Address vaginal or urinary symptoms
Improve libido
Overall wellbeing and quality of life
Unsure, I’d like guidance
HRT Suitability Screen
Have you ever had any of the following?
Blood clot (DVT/PE)
Stroke or TIA
Heart attack or coronary artery disease
Breast cancer
Endometrial (uterine) cancer
Unexplained vaginal bleeding
Severe liver disease
None of the above
Do you experience migraines with aura?
Yes
No
Unsure
Do you have a uterus?
Yes
No (hysterectomy)
Unsure
When was your last cervical screening test?
Within 5 years
More than 5 years
Never
Not sure
Not applicable
When was your last breast screen (mammogram/ultrasound), if applicable?
Up to date
Not up to date
Not applicable (age)
Not sure
What best describes your preference?
I’d like to discuss HRT options
I’d prefer non-hormonal options first
I’m open to both
Unsure
Would you like pathology organised if clinically indicated?
Yes
No
Unsure
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
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
Are you experiencing recent postpartum changes, iron deficiency, thyroid issues, or major stress?
Yes
No
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
PCOS
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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