Consultation - PrimeLife

Step 1 of 14 7% About 5 min left

Pre-Screen

About You

Why Are You Here?

Your TRT History

Your Health Background

Your Lifestyle

Aging Male Symptoms Scale

Patient Health Questionnaire

Sleep Apnea Screening

Blood Tests & Lab Work

Side Effects

Treatment Goals

Important Information

Declaration

Before you begin, please have the following to hand, if applicable:

A photo or document showing your current testosterone medication packaging (with your name visible), or a letter from your previous provider confirming your prescription.

Any recent blood test results from the last 6 months.

This form is not a diagnosis and does not guarantee that medication will be prescribed.

If you’re not currently taking TRT, we’ll email you a link to book a video consultation with a prescriber, after which your medication will be delivered.

1 Pre-Screen

Before we begin, we need to confirm a few things to make sure this service is right for you.

I confirm I am 18 years of age or older.

Have you ever been diagnosed with, or do you currently have, any of the following conditions?

Prostate cancer
Male breast cancer
Uncontrolled heart failure
A heart attack or stroke in the past 6 months
Severe untreated sleep apnea

Yes

What is your BMI?

Your BMI is calculated automatically from your height and weight. If your BMI is 30 or above, you may also be eligible for our weight loss programme, which could support your overall health goals alongside or as an alternative to TRT. This does not affect your TRT assessment.

Start Weight Loss Consultation (opens in new tab)

Please select either Metric or Imperial measurements :

Metric (Centimeters and Kilograms)

Imperial (Feet and Pounds)

Height

Feet

Inches

Weight

Stone

Pound

BMI Calculation:

What is your waist size?

If your waist size is ≥102 cm, you may also be eligible for our weight loss programme, which could support your overall health goals alongside or as an alternative to TRT. This does not affect your TRT assessment.

Start Weight Loss Consultation (opens in new tab)

Waist Measurement

Inches

I understand that blood testing is mandatory for diagnosis and safety as part of this pathway.

I confirm that the information I have provided above is accurate and complete.

2 About You

Tell us a little about yourself so we can personalise your assessment.

Are you a new patient or are you transferring from another provider?

New patient

Transferring from another provider

Full Legal Name

Date of Birth

Email Address

Phone Number

6 Your Lifestyle

A few questions about your day-to-day habits that may be relevant to your assessment.

10 Blood Tests & Lab Work

Let us know where you are with blood testing so we can advise on next steps.

Please upload proof of recent bloodwork

Only images or pdf accepted

File #1

File #2

File #3

File #4

File #5

Please upload proof of bloodwork

Only images or pdf accepted

File #1

File #2

File #3

File #4

File #5

11 Side Effects

Tell us about any side effects or changes you've noticed since starting TRT.

12 Treatment Goals

Help us understand what you're looking to achieve with your new provider.

13 Important Information

Please read and acknowledge the following before submitting your consultation.

I understand TRT is a long-term medical therapy
I understand TRT may cause side effects (acne, infertility, fluid retention, BP changes)
I understand regular lab monitoring is required
I agree to follow prescribed dosing only
I understand treatment may be modified or stopped for safety

14 Declaration

Almost done. Please confirm the information you’ve provided is accurate and complete.

I confirm that all information provided is accurate and complete

I understand that the prescriber will review my chosen medication before it is dispensed. If it is not considered appropriate for me, I will be informed and guided towards a suitable alternative.

AI Consultation Scribing Consent

I consent to my video consultation being scribed using AI, an NHS-verified clinical scribing tool. I understand this supports accurate clinical record-keeping and that scribed notes are only used within my clinical care. This is optional and will not affect your ability to proceed.

I consent

I do not consent

Full Name (Electronic Signature)

Date

1 Pre-Screen
2 About You
3 Why Are You Here?
4 Your TRT History
5 Your Health Background
6 Your Lifestyle
7 Aging Male Symptoms Scale
8 Patient Health Questionnaire
9 Sleep Apnea Screening
10 Blood Tests & Lab Work
11 Side Effects
12 Treatment Goals
13 Important Information
14 Declaration

Weight Loss Clinic

Men's Health

Longevity Coaching

Testosterone Replacement Therapy

1 Pre-Screen

I confirm I am 18 years of age or older.

Have you ever been diagnosed with, or do you currently have, any of the following conditions?

What is your BMI?

Height

Weight

Height

Weight

What is your waist size?

I understand that blood testing is mandatory for diagnosis and safety as part of this pathway.

I confirm that the information I have provided above is accurate and complete.

2 About You

Are you a new patient or are you transferring from another provider?

Full Legal Name

Date of Birth

Email Address

Phone Number

3 Why Are You Here?

What prompted you to seek testosterone therapy? (Select all that apply)

Please specify.

How long have you experienced these symptoms?

4 Your TRT History

Have you ever been prescribed testosterone therapy before?

Type of testosterone used:

Approximate dose & frequency:

When did you stop (if applicable)?

Reason for stopping:

Are you currently on testosterone therapy?

How long have you been on TRT (total time)?

Please upload proof of your current medication

Name of previous or current provider

Reason for switching providers: (Select all that apply)

Please specify reason:

Testosterone formulation currently used:

Please specify formulation:

Current dose:

Injection or application frequency:

Please specify frequency:

Route of administration:

Overall, how have you responded to TRT?

Which benefits have you experienced? (Select all that apply)

5 Your Health Background

Have you ever been diagnosed with any of the following? (Select all that apply)

Please provide details

Are you currently taking any prescriptions or over-the-counter medications?

List all current medications (prescription & OTC)

Are you currently taking any supplements or hormones?

List supplements or hormones

6 Your Lifestyle

Do you exercise regularly?

Alcohol use

Tobacco or nicotine use:

7 Aging Male Symptoms Scale

Decline in general well-being

Joint and muscular pain

Excessive sweating

Sleep problems

Increased need for sleep / fatigue

Irritability

Nervousness or anxiety

Physical exhaustion / lacking vitality

Decrease in muscular strength / endurance

Decreased motivation

Depressive mood

Feeling that you have passed your peak

Feeling burnt out / having hit rock-bottom

Decrease in beard growth

Decrease in ability and/or frequency to perform sexually

Decrease in number of morning erections

Decrease in sexual desire / libido

8 Patient Health Questionnaire

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating