MEDICAL QUESTIONNAIRE

TLEC offers prescription products. It is just like going to the doctor without having to go to the Doctor’s office. We require our clients to fill out a short medical questionnaire that contains the same questions a doctor would ask in a face to face consultation. This medical questionnaire is designed to evaluate that it is safe for you to commence treatment. Treatments have been proven to be safe and very effective, provided certain diseases are not present, overdoses are not consumed and possible side effects are checked.

Background


What products are you interested in? (Tick all that apply) *
NAD IV TherapySupplementsMedical InjectablesAll of the above

Personal Details





Address*









Sex* MaleFemale
Special offer code
How did you hear about us?*

Weight (kg) *
Height (cm) *

Medical Background

Do you suffer or have you ever suffered from any of the following conditions?

High blood pressure *
YesNo
Asthma *
YesNo
High cholesterol *
YesNo
Epilepsy *
YesNo
Stroke *
YesNo
Cold sores/shingles *
YesNo
Thyroid concerns *
YesNo
Liver disease *
YesNo
Chronic pain *
YesNo
Kidney disease *
YesNo
Breastfeeding *
YesNo
Pregnant/trying to conceive *
YesNo
Fibromyalgia *
YesNo
Heart disease *
YesNo
if Yes, Detail?
Mental health concerns *
YesNo
if Yes, Detail?
Cancer *
YesNo
if Yes, Detail?
Diabetes *
Type 1Type 2No
if Yes, Detail?
Smoker *
YesNo
if Yes, how many per day?
Alcohol – frequency & how many drinks *
Drug use – what/how often *
Other health concerns eg. Lifestyle, stress, sleep, digestive, autoimmune *

Do you experience any of the following?

Night sweats *
YesNo
Fevers *
YesNo
Reduced appetite *
YesNo
Severe fatigue *
YesNo
Unexplained weight loss *
YesNo
Any lumps e.g. breast, armpit, skin *
YesNo
If yes, do you know the reasons for these lumps
If Yes to any of the above, please provide details

Medications

Do you take any medications? *
YesNo

if Yes, what were they?

Current medications name
Daily dose / frequency

Allergies

Do you have any allergies to medications? *
YesNo

Medical Information

Customer verification

Medicare Number:
Individual Reference Number(IRN):

Or

GP Information (optional)

GP Name
Surgery Contact Number
Surgery Name
Surgery Address
Zip/Postal Code
I certify that all the information provided on this application is accurate to my knowledge