Simple Online Doctor

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Patient Notice: This assessment forms the basis of your consultation today. For your own safety, you must be honest and thorough with your answers including any current medicines, medical conditions or allergies. This will allow our doctors to safely prescribe your treatment and provide health advice.

1Your Thyroid

Have you previously been diagnosed with hypothyroidism by a doctor and been prescribed Eltroxin? *Eltroxin is stored at room temperature and is a different formulation and is NOT interchangeable with Eutroxsig and Oroxine without your doctor’s consultation. *

NoYes

What is your current daily Eltroxin dose (in micrograms)? *

How long have you been taking Eltroxin? *

Please provide more information below. *

Have you experienced any side effects from Eltroxin? *

NoYes

Please provide more details about side effects you have experienced with Eltroxin. *

Have you had a blood test to check your thyroid function in the last 12 months? *

NoYes

Could you please state what month and year your last test was to the best of your knowledge. *

Could you please state what month and year your last test was to the best of your knowledge *

Please provide the results of your last thyroid function test (TFT) including TSH, T3 and T4 levels. *

Failing to provide TSH, T3 and T4 results from your previous test may result in a delay to your order as we contact you to confirm these numbers.

Have you experienced any tremors, high blood pressure or heart palpitations (fast heart rate) since your last blood test? *

NoYes

Please provide more information below. *

2Your Health

Have you ever been diagnosed with, or suspected of having, thyrotoxicosis? *

NoYes

Please provide more information below. *

Have you ever been diagnosed with adrenal gland problems? *

NoYes

Please provide more information below. *

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs? *

NoYes

Please list any prescription, over the counter or alternative medicines you are taking, including the dose. *

Do you have any known allergies to any medications or substances? *

NoYes

Please enter known allergies and reactions. *

Do you have any other health problems or conditions that you think we should know about? (e.g. Myasthenia Gravis, any enzyme deficiencies or recent major operations etc.) *

NoYes

Please enter your current medical conditions or other health problems. *

Are you pregnant or planning to become pregnant or breastfeeding? *

NoYes

Please provide more information below. *

3Consent

I understand that I need to have regular reviews and blood tests from my GP regarding this medicine.
I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.
I agree to the Simple Online Doctor terms and conditions.

Confirm

We strongly advise that you inform your GP of any treatment you receive.
Would you like us to inform them on your behalf? If you are unsure, you can search your GP clinic information by clicking here.

NoYes

Please enter the email address of your GP clinic *

As per Australian telehealth guidelines, all first time patients, those requesting a new treatment or those looking to renew a prescription must have a brief video or phone call with one of our doctors. Do you have reliable access to the internet on a device which you can use to have a video conversation with our doctors? *

NoYes

You require reliable access to the internet on a device which you can use to have a video consultation with the doctor in order to be suitable for telehealth. Please refer to your regular GP in person.

During your consultation, our doctor will assess whether you are suitable for treatment. If you are, a prescription will be provided to and filled by our pharmacy partner and delivered to your chosen address. Any and all resupplies will be stored on your account and will be available for request from our service when required. For resupplies you will only need to pay for the medication and shipping, you will not be charged a consultation fee. Please confirm you understand this information. *

Confirm

If we are unable to assist via a telehealth consultation, you may be asked to seek alternative medical care such as that of a doctor in person. If this occurs you will receive a refund on your request.

Simple Online Doctor is a private clinic; the consultation and medication may be eligible for rebates through your private health cover, but are not covered by Medicare or the PBS. We conduct regular price reviews to ensure we are providing among the best value online.

Did you have difficulty understanding the English that is written in this assessment, affecting your ability to provide accurate answers or do you require language interpretation during a verbal consultation? *

NoYes

As you have difficulty understanding the assessment and or require interpretation services, you will be required to have an interpreter with you during your consultation with the doctor. You can access these services at Translating and Interpreting Services. Please confirm that you agree to organise an interpreter for your consultation.

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Assessment Progress

Assessment

1Your Thyroid

2Your Health

3Consent

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1Your Thyroid

2Your Health

3Consent

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