Weight Loss Questionnaire Verification

Confirmation Required

If you proceed with an order, our doctor will call you on the below number to explain potential side effects and answer any questions you may have. Please ensure that your phone number is correct as the doctor cannot write a prescription without speaking with you first.

Answer seven quick questions about your general health to get the most effective clinically proven treatments for you.
DO YOU AGREE AND CONSENT TO THE FOLLOWING?
  • I live in Australia.
  • I shall be the sole user of any medication offered to me through this service.
  • I confirm all answers are provided by me, and will be truthful.
  • I agree to the terms and conditions.
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1
Would you like to skip the questionnaire and speak with a Doctor instead?
NEW
2
Do you take any regular medications, have any known allergies or any medical issues?
3
Please list any regular medications you take, any known allergies or any medical issues.

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4
Do you have a medication preference?
5
Enter the name of medication below
Burst Health does not prescribe this medication. Please visit your regular GP.
6
Please select your preferred strength
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7
Have you taken 40mg before?
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1
Would you best describe yourself as underweight, normal weight, overweight, obese, or superobese? *
2
Have you tried anything previously for weight loss? *
3
What have you tried?

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4
Do any of the following apply to you?
  • Anxiety disorders
  • Hyperthyroidism
  • Hypothyroidism
  • History of drug or alcohol abuse or dependence
  • Concomitant treatment with monoamine oxidase inhibitors
  • Pregnancy and breastfeeding
  • Hypertension
  • History of cardiac arrhythmias, or seizures
  • History of diabetic retinopathy, gallbladder problems, pancreatitis
  • Concurrent use of antidiabetic medication or insulin
5
Please tell us more about the condition you do have.

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6
Are you taking any medications (including over the counter or herbal medicines)? Do you have any other medical condition or previous operations not already mentioned?
7
Please list all your medications you take and any other medical conditions or previous operations.

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7
Do you have hypertension or take antidepressant medication? *
8
Have you tried weight loss pills?*
9
What was the medication? What dose have you taken before? Did the medication help? Were there any side effects?

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10
Please enter your height in centimetres and weight in kilograms? *
cm
kg
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12
Discretion is at the heart of what we do but for legal reasons the name on your prescription must be your full legal name. Please provide your legal name as per your official government ID.

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13
Please enter your date of birth. *
/
/
Please use this format (DD/MM/YYYY)
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13
Based on your medical history and individual needs, our doctors have provided personalised treatment. Please complete your mobile phone number to view recommended treatment. *
11
Available treatments
12
We require a full-body shot photo of you either standing in front of a mirror or taken by someone else. Your face does not need to be in the photo.
  • Take Photo
    • 13
    Please provide your sex at birth and waist circumference in centimetres *
    cm
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    15
    Do you have a Medicare card?
    14
    Do you agree to use Burst Health's preferred pharmacy provider to ensure the fastest delivery time of your prescribed medication?
    15
    Do you have an NHI?
    17
    What is your NHI?

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    15
    Please enter your Medicare Card details
    /
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    15
    What is your IHI?
    Your IHI is located next to your Covid vaccine certificate. If you are an international student or working visa holder, for our doctors to write a prescription, you first need to register for myGov and an IHI (Individual Health Identifier). You can do this all online within minutes. Please take a look at the Services Australia website for complete instructions, click here.
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    BOOKS CLOSED IN NEW ZEALAND
    Due to overwhelming demand, we are not currently accepting new patients. For existing patients, please access your account here.
    Unfortunately you are not eligible for 40mg as you have never taken it before. Please select a different strength.
    If you made a mistake, you can go back and correct your answer.
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    Unfortunately you would not be suitable for our monthly treatment plan. Please book a consult with your local GP.
    If you made a mistake, you can go back and correct your answer.
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    Unfortunately based on your answer you would not be suitable for treatment. If you would like to speak with the Burst doctor to discuss other treatment options, please book an appointment here.
    If you made a mistake, you can go back and correct your answer.
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    Please follow this link to book a $85 consultation with our doctor:
    Click here to book If you made a mistake, you can go back and correct your answer.
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    Thank you for filling out the form.

    It has been sent to our doctor for review.

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