insomnia questionnaire

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.
press Enter ↵
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.

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
1
Please provide your sex at birth*
2
How long have you been suffering from Insomnia?*

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
2
Do you have any allergies or special medical conditions? *
3
Please enter any allergies or special medical conditions *

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
4
Do you take any medications?*
5
Enter any medications you take or have previously taken *

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
5
Did you get a good result from it? *
6
Did you have any side effects from it? *

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
8
Are you pregnant or breastfeeding? *
11
Are you suffering from any mental illnesss *
12
Please explain what mental illness you are suffering from? *

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
13
Is there anything else you like to tell your Doctor? *
14
What would you like to tell your Doctor? *

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
15
Please enter your date of birth. *
/
/
Please use this format (DD/MM/YYYY)
press Enter ↵
16
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. *

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
17
Based on your medical history and individual needs, our doctors have provided personalised treatment. Please complete your mobile phone number to view recommended treatment. *
press Enter ↵
15
Do you have a Medicare card?
15
Please enter your Medicare Card details
/
press Enter ↵
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.
press Enter ↵
4
Do you have a medication preference?
5
Enter the name of medication below
6
Please select your preferred strength
7
Have you taken 100mg before?
press Enter ↵
6
How many uses?
7
Do you prefer?
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.
press Enter ↵
Please follow this link to book a $35 consultation with our doctor:
Click here to book If you made a mistake, you can go back and correct your answer.
press Enter ↵

Thank you for filling out the form.

It has been sent to our doctor for review.

0% completed