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2025 | INSIGHTS + MEDICAL HISTORY + SCREENINGS

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Step 1 of 12 - Personal Information

At Ageing Solutions we take your health and wellbeing seriously. In order for our Medical Team to provide you with a personalised treatment program and our integrative medical solutions, you will be required to complete our registration process. It is essential that during this process you provide us with your most up to date medical information including any current medications, health concerns and/or injuries, as well as any upcoming and/or past surgeries.

As per Australian Regulations, our Medical Team must have your current medical information before displaying Schedule 4 Medications and Supplements.

We also take your privacy seriously and manage your private information with the utmost care and consideration. We will not pass your details or information onto any third party and our Medical Team will only contact you if you place an order with us.

We thank you for your cooperation and understanding. If you have any questions please do not hesitate to contact our Customer Service Team on 1300 100 490.

Email Address*

Username

Password*

Enter Password Confirm Password

Full Name*

First Name Last Name

Phone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

DD dash MM dash YYYY

I confirm I am over 18 years old*

Gender*

Male

Female

Other / Prefer not to say

Promotions and Product Launches

Subscribe to our newsletter to receive exclusive promotions and be first to know about product launches

INITIAL INSIGHTS

Please indicate your health Interests by ticking the relevant boxes below:*

Please select all that apply.

Weight Loss

Muscle Development

Repair and Recovery

Sexual Health

Focus and Cognitive Performance

Gut Health

Immunity

Mood and Sleep

Anti Ageing

How did you find out about us?*

Doctor Referral

Friend / Family Recommendation

Google / Search Engine

Social Media

Other

If other, please provide details*

How would you rate your overall fitness?*

5 Stars = Fantastic | 0 Stars = Poor

★★★★★

★★★★☆

★★★☆☆

★★☆☆☆

★☆☆☆☆

☆☆☆☆☆

How would you rate your overall health?*

5 Stars = Fantastic | 0 Stars = Poor

★★★★★

★★★★☆

★★★☆☆

★★☆☆☆

★☆☆☆☆

☆☆☆☆☆

Have you been prescribed any of the below medications in the past?

Please select all that apply.

Cannabis

Peptides

Viagra or Cialis

Hair regrowth medications

GLP1 weight loss medication

Hormone Replacement Therapy

MEDICAL INFORMATION

For your health and safety it is essential that you provide our Medical Team with your most up to date medical history. This should include any current medications and health conditions as well as your medical history and past surgeries or injuries.

The medical information you provide will be confidential and only used as per our current Terms and Conditions

If you have any questions or concerns about how your confidential medical questionnaire will be stored or used please contact us.

What is your sex assigned at birth?*

Male

Female

Height (cm)*

Please enter a number from 50 to 250.

Weight (kg)*

Please enter a number from 30 to 300.

Do you have any current medical conditions?*

Yes

If yes, please provide details.*

Do you have any known allergies, intolerances or anaphylaxis history?*

Yes

If yes, please give more details*

Are you taking any prescribed medications?*

Yes

If yes, please list the medication name, dosage and reason for use.*

Are you taking any supplements NOT prescribed by a GP?*

Yes

If yes, please provide details.*

Do you suffer from any muscular, connective tissue, ligament issues or conditions?*

Yes

If yes, please provide details.

Have you had any surgical procedures in the past 4 weeks or have any planned for the next 4 weeks?*

Yes

If yes, please provide details.*

Have you ever been diagnosed with cancer?*

Yes

If yes, please provide details.*

Do you have a family history of cancer?*

Yes

If yes, please provide details.*

Have you ever been diagnosed with epilepsy?*

Yes

If yes, please provide details.*

Have you ever been diagnosed with diabetes or abnormal blood sugar levels?*

Yes

If yes, please provide details.*

Have you ever suffered from blood clots?*

Yes

If yes, please provide details.*

Do you have any history of high blood pressure?*

Yes

If yes, please provide details.*

When was the last time you had your blood pressure taken?*

1 - 3 months ago

3 - 6 months ago

6 - 12 months ago

12+ months ago

Have you ever had a stroke?*

Yes

Have you been diagnosed with any heart conditions?*

Yes

If yes, please provide details.*

Do you suffer from chest pains, palpitations (irregular or fast heart rate), shortness of breath with exercise?*

Yes

If yes, please provide details.*

Are you trying to conceive?*

Yes

Do you smoke?*

Yes

If yes, please provide details.*

Do you consume alcohol?*

Yes

If yes, please provide details.*

Have you ever taken anabolic steroids, peptides, or hormone replacements in the past?*

Yes

If yes, please provide details.*

Do you suffer from anxiety or depression?*

Yes

If yes, please provide details.*

Do you suffer from fatigue?*

Yes

If yes, please provide details.*

Do you have any lumps breast, armpit, groin areas?*

Yes

If yes, please provide details.*

Do you suffer from night sweats or fevers?*

Yes

If yes, please provide details.*

Do you suffer from unexplained weight loss?*

Yes

If yes, please provide details.*

Do you suffer from reduced appetite?*

Yes

If yes, please provide details.*

Do you suffer from or have a history of thyroid conditions?*

Yes

If yes, please provide details.*

Is there any other medical information you would like the medical team to know?*

Yes

If yes, please provide details.*

ANTI AGEING

How would you rate your skin's elasticity, fine lines and wrinkles?*

1 - Very poor skin elasticity, very noticeable lines and wrinkles

2 - Poor elasticity, noticeable lines and wrinkles

3 - Moderate elasticity, some lines and wrinkles

4 - Some loss of elasticity, lines and wrinkles not noticeable

5 - Excellent elasticity, lines and wrinkles not noticeable

How would you rate your energy and stamina?*

1 - Very low energy and stamina

2 - Low energy and stamina

3 - Moderate energy and stamina

4 - Good energy and stamina

5 - Excellent energy and stamina

Have you noticed a decrease in your metabolism?*

Yes

Have you noticed soreness after daily tasks?*

Yes

How would you rate your stress when undertaking simple tasks?*

1 - No stress at all

2 - Minimal stress

3 - Moderate stress

4 - High amounts of stress

5 - Extremely stressed

IMMUNITY

How many times a year do you get a cold or the flu?*

0 times a year

1 - 2 times a year

3+ times a year

Do you have a compromised immune system from a previous health-related issue?*

Yes

Are you currently undergoing radiation treatment?*

Yes

Are you currently undergoing chemotherapy?*

Yes

Are you currently undergoing any kind of medication therapy?*

Yes

Do you suffer from a gut-related injury or problem?*

Yes

Have you been diagnosed with Crohn's disease?*

Yes

Have you been diagnosed with Irritable Bowel Syndrome?*

Yes

Do you suffer from digestive or gut issues stemming from anxiety or depression symptoms?*

Yes

Do you suffer from stomach ulcers?*

Yes

How do you rate your overall gut health?*

1 - Very poor

2 - Poor

3 - Moderate

4 - Good

5 - Excellent

How do you rate your overall health and wellbeing?*

1 - Very poor

2 - Poor

3 - Moderate

4 - Good

5 - Excellent

REPAIR + RECOVERY

Are you currently suffering from an injury?*

Yes

How old is your injury?*

1 - 12 months

1 - 3 years

3 - 5 years

5+ years

Are you currently suffering from inflammation and/or pain from the injury?*

Yes

How would you rate your current pain in relation to your injury?*

1 - Little to no pain

2 - Some pain

3 - Moderate pain

4 - Great pain

5 - Extreme pain

Are you taking any pain relief medication?*

Yes

Is the inflammation localised to the injured site?*

Yes

How would you rate your current inflammation?*

1 - Little to no inflammation

2 - Some inflammation

3 - Moderate inflammation

4 - A lot of inflammation

5 - Extreme inflammation

Have you had any reconstructive surgery for the injury?*

Yes

Is your current injury affecting your sleep?*

1 - No impact on sleep

2 - Some negative impact on sleep

3 - Moderate negative impact on sleep

4 - Sleep is very negatively impacted

5 - Sleep is extremely negatively impacted

Do you suffer from any muscular injuries?*

Yes

Do you suffer from any bone injuries?*

Yes

Do you suffer from any brain injuries?*

Yes

Do you suffer from any tendon injuries?*

Yes

MOOD + SLEEP

How would you rate your anxiety levels?*

1 - No anxiety

2 - Some anxiety

3 - Moderate anxiety

4 - High anxiety

5 - Extremely high anxiety

Are you currently taking any prescribed medications for your anxiety or mood?*

Yes

What kind of prescribed medication do you take for your anxiety or mood?*

SSRI (Selective serotonin reuptake inhibitors)

SNRI (Serotonin-norepinephrine reuptake inhibitors)

Tricyclic antidepressants

Monoamine oxidase inhibitors

Beta-blockers

Buspirone

Benzodiazepines

Other

How frequently do you take your prescribed anxiety or mood medication?*

Once a week

Once every few days

Daily

Multiple times a day

How much difficulty do you have falling asleep?*

1 - No difficulty

2 - Some difficulty

3 - Moderate difficulty

4 - High difficulty

5 - Extremely high difficulty

Do you have trouble staying asleep?*

Yes

How many times do you wake up during the night?*

0 times a night

1 - 2 times a night

3 - 4 times a night

5 + times a night

How tired do you feel in the morning after a full night's sleep?*

1 - Well rested

2 - Somewhat tired

3 - Moderately tired

4 - Very tired

5 - Extremely tired

How busy does your mind feel when attempting to sleep?*

1 - Quiet mind and thoughts

2 - Some business

3 - Moderate business

4 - Very busy

5 - Extremely busy mind and thoughts

Are you currently taking any prescribed sleep medications?*

Yes

What kind of prescribed sleep medication do you take?*

Temazepam

Zopiclone

Zolpidem

Diazepam

Melatonin

Other

On average, how many nights per week do you take these medications?*

Once a week

Once every few days

Every night

MUSCLE DEVELOPMENT

How many times per week do you train?*

0 times per week

1 - 2 times per week

3 - 4 times per week

5+ times per week

How is your stamina and energy during a 45 minute workout?*

1 - Poor

2 - Fair

3 - Good

4 - Excellent

How sore is your recovery post training?*

1 - Extremely sore

2 - Very sore

3 - Somewhat sore

4 - No issues with soreness

Does your body have good muscle retention?*

Yes

Do you find that lately your strength has decreased?*

Yes

Are you looking to gain muscle or tone?*

Muscle

Tone

Both

N/A

Do you have any recent medical conditions that could affect your muscle mass?*

Please choose "Yes" and explain any recent medical conditions if you are unsure of impact and effect.

Yes

If yes, please provide details.*

WEIGHT LOSS

How much weight are you aiming to lose (in kilograms)?*

1 - 3 kg

4 - 7 kg

8 - 10 kg

11+ kg

N/A

Have you ever been prescribed Ozempic or a Semaglutide-based product in the past?*

Yes

If yes, when was your last dose?*

1 - 2 weeks ago

2 - 4 weeks ago

4+ weeks ago

Do you follow any kind of diet regime or program?*

Calorie-restricted diet

Ketogenic diet

Macro diet

I do not have a diet

What is a rough estimate of the amount of calories you currently consume in a day?*

1000 - 1500 calories per day

1500 - 2000 calories per day

2000 - 2500 calories per day

2500+ calories per day

Not sure

Do you find yourself out of breath when exercising?*

Yes

On average, how many days a week do you exercise?

1 day

2 days

3 days

4 days

5+ days

What type of exercise do you usually engage in?*

Cardio-based

Weight-based

HIIT-based

Yoga / Slow movements

N/A

Where do you find you are holding the most stored fat?*

Chest / flank / stomach

Stomach / hips

Arms / stomach / thighs

Chest / hips / thighs

How does your current weight concern you or affect your confidence?*

1 - No concern or impact at all

2 - Somewhat concerned and impacted

3 - Moderately concerned and impacted

4 - Very concerned and impacted

5 - Extremely concerned and impacted

SEXUAL PERFORMANCE

How often are you sexually active per week?*

0 times per week

1 - 2 times per week

3 - 5 times per week

5+ times per week

Do you have problems getting aroused?*

Yes

Do you have trouble getting or maintaining an erection?*

Yes

Rate the firmness of your erection.*

1 - Firm with no concerns

5 - Flaccid and unable to perform

N/A

1 - Firm with no concerns | 5 - Flaccid and unable to perform

How long does your sexual activity last (not including foreplay)?*

1 - 5 minutes

5 - 10 minutes

10 - 15 minutes

15 - 30 minutes

30+ minutes

I am not sexually active

Approximately how long is your refractory period?*

Less than 30 minutes

30 minutes - 1 hour

1 - 6 hours

6+ hours

I am not sexually active

SEXUAL PERFORMANCE

How often are you sexually active per week?*

I am not sexually active

1 - 2 times per week

3 - 5 times per week

5+ times per week

How would you rate your arousal and libido?*

1 - Little to no libido, trouble feeling aroused

2 - Low libido, some trouble feeling aroused

3 - Moderate libido, little trouble feeling aroused

4 - High libido, rarely have trouble feeling aroused

5 - Very high libido with no trouble feeling aroused

Do you have trouble with self lubrication?*

Yes

Do you have trouble reaching orgasm?*

Yes

How long does your sexual activity generally last (not including foreplay)?*

1 - 5 minutes

5 - 10 minutes

10 - 15 minutes

15 - 30 minutes

30+ minutes

I am not sexually active

Approximately how long is your refractory period?*

Less than 30 minutes

30 minutes - 1 hour

1 - 6 hours

6+ hours

I am not sexually active

Do you experience dyspareunia or any form of pain during sexual intercourse?*

Yes

Have you ever experienced any kind of abnormal vaginal bleeding?*

Yes

Do you suffer from endometriosis?*

Yes

Do you suffer from polycystic ovary syndrome (PCOS)?*

Yes

TERMS OF SERVICE AND MEDICAL CONSENT

Please read these statements carefully and provide your consent.*

TERMS OF SERVICE AND MEDICAL CONSENT FORM

To finalise your registration and become a patient with AS Wellness by Ageing Solutions, you must read the statements below and agree by signing and using the check box provided.

Once you have successfully consented and submitted your registration form you will become a patient and receive confirmation via your nominated email address. Patients have full access to browse the full range of peptides, medication and supplements we supply, as well as place an order.

Please read these statements carefully and provide your consent.

—

I understand that AS Wellness by Ageing Solutions doctors prescribe based on my individual health history and needs. This includes a combination of supplements, vitamins and minerals along with TGA approved medications, scheduled medications and special access medications such as CBD, THC, peptides and other compounded medications.

I understand that peptides, CBD, and THC are still classed as research medications, and as such the human data and medical research on these are limited. I understand that peptides, however, are compositionally two or more amino acids linked together. Peptides have less than 50 amino acids in total, where proteins have more than 50, and these products have been used in the anti-ageing field for over 40 years.

I acknowledge that any non-prescription supplements, vitamins and minerals purchased from AS Wellness by Ageing Solutions are taken at my own risk and are not prescribed by a medical professional.

I agree that AS Wellness by Ageing Solutions reserves the right to refuse access to their service or supply of products to any individual based on any criteria they deem necessary.

I understand that if I do not follow the dosing and administration instructions from the prescribing doctor or pharmacy that I will be wholly responsible for any issues I experience.

I acknowledge that AS Wellness by Ageing Solutions reserves the right to refuse me as a patient if I do not follow the doctor's instructions. I agree that AS Wellness by Ageing Solutions reserves the right to refuse access to their service or supply of products to any individual based on any criteria they deem necessary.

I have provided the most truthful and up to date information in my medical history and registration form, and acknowledge that failing to do so or purposely providing fraudulent information gives AS Wellness by Ageing Solutions the right to refuse service as well as pursue legal action if necessary. If any information provided in my medical history or registration form changes I agree to notify the team as soon as possible, and will keep them informed of any changes to my medical history or medication.

I understand that peptides are still classed as research medications and that the human data and medical research on these medications are limited.

I give the AS Wellness by Ageing Solutions Patient Care Team permission to contact me by phone or email for any reason relating to the service, including to update my medical history, request pathology or further clarification and even to consult me about product selection.

I acknowledge that the Medical Team will send confirmation to my nominated email address once my product selection has been approved and scripted based on the medical history provided.

I consent to being contacted by the Medical Team via phone or email if there is any further information required.

If the doctor refuses to prescribe my selected medication, I consent to being contacted to find an alternative medication or issue a refund. I understand that a comprehensive consultation with my prescribing doctor is available at an extra cost.

I agree to inform AS Wellness by Ageing Solutions of any adverse reactions to medications or supplements supplied by AS Wellness by Ageing Solutions as soon as possible.

I understand that AS Wellness by Ageing Solutions does not hold any compounded products or medication on hand and all medications & supplements are compounded as scripted by Australian only sterile compounding pharmacies. I understand that medications are sent from the pharmacy directly to the patient.

I comprehend that all S4 medications are custom-compounded based on prescriptions. This implies that the pharmacy doesn't commence compounding the medication until they've received the prescription from the doctor at AS Wellness by Ageing Solutions. It may take 10 to 14 business days before the medication is dispatched to my approved shipping address.

I acknowledge that the Medical Team will send confirmation to my nominated email address once my product selection has been approved and scripted based on the medical history provided.

I consent to being contacted by the Medical Team via phone or email if there is any further information required.

If the doctor refuses to prescribe my selected medication, I consent to being contacted to find an alternative medication or issue a refund. I understand that a comprehensive consultation with my prescribing doctor is available at an extra cost.

I agree to inform AS Wellness by Ageing Solutions of any adverse reactions to medications or supplements supplied by AS Wellness by Ageing Solutions as soon as possible.

I understand that AS Wellness by Ageing Solutions does not hold any compounded products or medication on hand and all medications & supplements are compounded as scripted by Australian only sterile compounding pharmacies. I understand that medications are sent from the pharmacy directly to the patient.

I understand that AS Wellness by Ageing Solutions may not have every supplement or medication available that the doctor has suggested. I agree that my information can be shared with a sister company in common directorship, who can supply that specific product or medication. I agree that a representative from that company can contact me if further information is required.

I confirm that I am not dependent on this medication and am taking it purely for anabolism purposes.

I understand the indications, protocols and treatments may not appear in official medical guidelines and as a result, may not be accepted by a majority of medical doctors. I have been offered the opportunity to seek a second opinion if desired.

I understand some products may be off label and not TGA approved.

I comprehend that all S4 medications are custom-compounded based on prescriptions. This implies that the pharmacy doesn't commence compounding the medication until they've received the prescription from the doctor at AS Wellness by Ageing Solutions. It may take 10 to 14 business days before the medication is dispatched to my approved shipping address.

I agree to all statements above and the website terms and conditions.*

I consent to my de-identified (statistical) medical data to be used for future medical research. I understand that this data does not contain my identifiable personal information.*

I consent to my de-identified (statistical) medical data to be used for future medical research. I understand that this data does not contain my identifiable personal information.**

I consent to my file / medical information being handled by non-AHPRA registered individuals, I acknowledge and understand that they will adhere to confidentiality and privacy regulations.*

I consent to my file / medical information being handled by non-AHPRA registered individuals, I acknowledge and understand that they will adhere to confidentiality and privacy regulations.**

Signature*

Our Solutions

Pathology

Gravity Forms Testing

2025 | INSIGHTS + MEDICAL HISTORY + SCREENINGS

INITIAL INSIGHTS

MEDICAL INFORMATION

ANTI AGEING

IMMUNITY

REPAIR + RECOVERY

MOOD + SLEEP

MUSCLE DEVELOPMENT

WEIGHT LOSS

SEXUAL PERFORMANCE

SEXUAL PERFORMANCE

TERMS OF SERVICE AND MEDICAL CONSENT