MEDICAL QUESTIONNAIRE

NAD Australia 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 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

Current Medical History

Uncontrolled diabetes mellitus *
YesNo
Uncontrolled thyroid disease *
YesNo
Uncontrolled heart disease *
YesNo
Benign intracranial hypertension *
YesNo
Proliferative or pre-proliferative diabetic retinopathy *
YesNo
Any form of cancer *
YesNo
Do you have any current medical or surgical problems? *
YesNo
Are you currently pregnant or breastfeeding? *
YesNo

Past Medical History

Have you ever been admitted to hospital? *
YesNo
Have you had any form of cancer in the past? *
YesNo
Thyroid disease *
YesNo
Heart disease *
YesNo
Other

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