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ignite@primalzone.com.au

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YOUR BEST UNLEASHED.

Primal Zone Quiz

Step 1/18

LET’S START WITH YOUR DETAILS

We’ll use this to send your results and book your consultation.
This assessment takes approximately 5 minutes to complete.

First name

Last name

Email

Phone

What type of work do you do?

Age range

Height (cm)

Weight (kg)

Your BMI --

UnderweightHealthyOverweightObese

WHAT’S YOUR PRIMARY GOAL?

Select the one that matters most to you right now.

Would you like to add a secondary goal? (Optional)

Which symptoms are you experiencing?

Select all that apply to you.

Symptoms

How long has this been going on?

Select one option.

What's your main goal right now?

Select the one that matters most.

CURRENT MEDICATIONS

This helps us ensure safe treatment options.

Are you taking any prescription medications?

Any supplements, hormones, or peptides?

MEDICAL CONDITIONS

Select any that apply to you.

Liver conditions?

Kidney disease?

Cardiovascular disease?

Chronic pain conditions?

Mental health conditions?

Currently being treated?

Sleep apnoea?

LIFESTYLE & SUBSTANCE USE

Do you smoke or vape?

Recreational drug use?

Do you consume alcohol?

How many standard drinks per week?

ACTIVITY & EXERCISE

What's your activity level at work?

How often do you exercise?

What type of exercise?

SLEEP & RECOVERY

How many hours of sleep per night?

Any sleep difficulties?

Do you use any sleep aids?

BLOOD TEST HISTORY

TRT requires blood test verification.

Have you had blood tests in the past 12 weeks?

Were they taken before 10am?

Were they taken fasting?

Have you had two separate low testosterone results?

TRT CONTRAINDICATIONS

Have you ever been diagnosed with any of the following?

CURRENT TRT STATUS

Are you currently on TRT?

Upload your pre-TRT blood results (optional)

This helps our doctors understand your baseline levels.

Click to upload

FERTILITY CONSIDERATIONS

TRT can affect fertility. Please answer honestly.

Are you planning to conceive in the next 12-18 months?

Have you previously fathered a child?

Do you understand that testosterone can suppress fertility?

Would you like to discuss fertility-preserving options?

BLOOD TEST UPLOAD

Upload your testosterone blood test results.

Do you have testosterone bloods from the last 12 weeks?

Upload your blood test results

PDF or images accepted (max 10MB).

Click to upload

NUTRITION

Do you track calories or macros?

What best describes your diet?

ALMOST DONE!

Just a couple more questions.

Support & Check-ins

We generally check in with all patients every 6 weeks to let the medication settle in, but you'll always have contact with us if you need it sooner.

Anything else the clinical team should know? (Optional)

IDENTITY VERIFICATION

Required for telehealth prescriptions in Australia. Your details are encrypted and stored securely.

Medicare Card Details

Medicare Card Number

IRN (Reference Number)

Expiry Date

Photo ID (Driver's Licence)

Upload a clear photo of the front of your driver's licence. This is used to verify your identity for prescription medications.

Click to upload photo

JPG, PNG or HEIC (max 10MB)

How much weight do you want to lose?

What have you tried so far?

Select all that apply.

Previous approaches

Any of the following apply?

WHAT LEVEL OF SUPPORT WORKS FOR YOU?

CURRENT MEDICATIONS

This helps us ensure safe treatment options.

Are you taking any prescription medications?

Any supplements, hormones, or peptides?

MEDICAL CONDITIONS

Select any that apply to you.

Liver conditions?

Kidney disease?

Cardiovascular disease?

Chronic pain conditions?

Mental health conditions?

Currently being treated?

Sleep apnoea?

LIFESTYLE & SUBSTANCE USE

Do you smoke or vape?

Recreational drug use?

Do you consume alcohol?

How many standard drinks per week?

ACTIVITY & EXERCISE

What's your activity level at work?

How often do you exercise?

What type of exercise?

SLEEP & RECOVERY

How many hours of sleep per night?

Any sleep difficulties?

Do you use any sleep aids?

NUTRITION

This helps us tailor the safest and most effective plan.

Do you track calories or macros?

What best describes your diet?

WEIGHT LOSS HISTORY

What have you previously tried for weight loss?

ALMOST DONE!

Just a couple more questions.

Support & Check-ins

We generally check in with all patients every 6 weeks to let the medication settle in, but you'll always have contact with us if you need it sooner.

Anything else the clinical team should know? (Optional)

IDENTITY VERIFICATION

Required for telehealth prescriptions in Australia. Your details are encrypted and stored securely.

Medicare Card Details

Medicare Card Number

IRN (Reference Number)

Expiry Date

Photo ID (Driver's Licence)

Upload a clear photo of the front of your driver's licence. This is used to verify your identity for prescription medications.

Click to upload photo

JPG, PNG or HEIC (max 10MB)

WHAT'S YOUR TOP PRIORITY RIGHT NOW?

WHAT WOULD YOU LIKE TO IMPROVE?

Select all that apply.

What's your training like right now?

WHAT'S HOLDING YOU BACK?

Select all that apply.

Openness to clinical support

WHAT TYPE OF INJURY ARE YOU DEALING WITH?

TELL US MORE ABOUT YOUR INJURY

How long has this been bothering you?

Pain level today: 5/10

No painSevere

Have you tried anything so far?

WHAT’S YOUR RECOVERY GOAL?

WHAT ARE YOU EXPERIENCING?

Select all that apply to you.

WHAT HAVE YOU TRIED SO FAR?

Select all that apply.

How long has this been going on?

WHAT DO YOU WANT TO ACHIEVE?

Select all that matter to you.

By submitting, you agree we may contact you about your results and next steps.