Clone of INTAKE New Client (Adult)

CONFIDENTIAL NEW CLIENT INTAKE FORM

Your Health History, Stress Status & Expectations for Care
Thank You for your trust!

You've made a great choice seeking help from
Adjust to Life Chiropractic - Noosa

Please watch this short video,
then complete this form with as much detail as you can.
(You need to watch the vid to proceed!)
As you progress through this form,
please click on these 'arrow' icons to expand
a new section and hide a completed section!

Privacy Statement & Consent
As of 12 March 2014, The Australian Privacy Principles (an amendment to the Privacy Act 1988 (Commonwealth)) apply to us, and the information about you that we collect.

Privacy Statement
Adjust to Life Chiropractic - Noosa collects personal information about you for the primary purpose of providing a health-care service to you (thorough assessment, analysis of your presenting situation and the ongoing provision of high-quality professional care).

We recognise and support your right to privacy in relation to this information and will at all times handle personal data with care and in strict confidence as per our professional and legal requirements.

If you do not provide this information, we may be unable to provide you with appropriate care.

This information is also used for:
- Administrative purposes involved with running this health centre;
- Billing you for services rendered;
- Use within the health centre when discussing your case with, or passing your case to another practitioner within the health centre for your ongoing management; or for staff training to ensure sensitivity and awareness of your health status and outcomes relating to your care;
- Disclosure of information to your doctors and/or other health professionals to facilitate communication and best possible care for you; and
- In the case of insurance or compensation claim it may be necessary to disclose and/or collect information that concerns your return to work to an insurer or your employer.
To ensure the provision of quality care and to operate with best practice, information about your assessment results and progress may be used by or disclosed to other relevant service providers and staff, who are involved in your management. These may include your doctors, specialists, insurers, solicitors or employers.

At times, this health centre may collect de-identified data for secondary purposes such as case-study publication or other research as part of a practice-based research network. You will always be consulted and your explicit permission sought if your data is required for such purposes. There is no expectation or obligation for you to agree.

Beyond these purposes we do not disclose your personal information to other parties (either local or overseas) unless required to by law.

Adjust to Life Chiropractic - Noosa has a Privacy Policy available on request (please ask any staff member). We invite you to read our Privacy Policy and to contact our privacy officer if you would like to discuss this matter further. Our privacy policy provides guidelines on how we collect, use, disclose and secure your information, and also contains information on how you may request access to, and/or correction of, your personal information and how you may complain about a breach of your privacy and how we will deal with such a complaint.

Our centre staff will demonstrate integrity and understanding by protecting and keeping secure your personal information.
Please acknowledge each of the following statements:*

I have read this Privacy Collection Statement. I understand the reasons for collection of my personal information and how this information may be used and disclosed. I agree to this use and disclosure.
I understand that it is my choice as to what information I provide and that withholding or falsifying information might act against the best interests of my assessment and the progress of my care.
I am aware that I can access my personal information and records of care on request and if necessary, correct information that I believe to be inaccurate.
I understand that if, in exceptional circumstances, access is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me.
I have been provided with or have been given an opportunity to obtain a copy of Adjust to Life Chiropractic Noosa's privacy policy.
Please type your name...*

First NameLast Name
and enter today's date:*

DayMonthYear
Date

Please let us know how you found us!

Most of our new clients are referred by friends, family, a colleague, or another health professional.
Part of our mission is to continually grow an actively participating, vibrant, energetic community of people engaged with seeking an optimal life.
Who may we thank for recommneding us to you?*

I wasn't referred directly. I found you by other means.Other
Great!

We do (of course!) welcome you WARMLY.
We care for every person as a VIP referral ANYWAY!
Other ways of finding us:*
Where did you find our ad?
When was this?

DayMonthYear
Date
Was it:

Here at our Health Centre?Other
We gratefully acknowledge and welcome YOU referring
your friends, colleagues and loved ones!

We aim to provide you with exceptional care and outstanding results;
when we do, please refer others in to see us!

By doing this, you help us achieve our vision of a vibrant, extraordinarily healthy community!
As part of our privacy policy, we require your 'opt out' if you object to referral acknowledgements:
Tick only if you do NOT agree to the following:

A thank-you letter or other form of acknowledgement being given to the person who referred you to us.Your name being displayed on our referral board when your refer a new person in to us.

Personal Info

Let's start with some admin basics to begin a client file for you...

Your Name and Photo!
If you have a camera on your device, please take a photo and upload it, so we can recognise you when you arrive!
Please enter your full legal name:
Title:*
First:*
Last:*
Suffix:
How would you like our staff to address you?*
Do you have a preferred name?
Which is?

Important Information
Sex*
Birth Date*

DayMonthYear
Height (cm)
(approx)
Weight (kg)
(approx)
Relationship Status*
Spouse/Partner's Name?

Your Addresses
Home Address:*
Different Postal?*

YesNo
Postal Address:

How Do We Contact You?
E-mail Address:*
Your e-mail is critical for our communication with you
Mobile:*
Home:
Work:
Best methods to contact you? (you can select more than one)*
Preferred time to contact you? (you can select more than one)*
We make contact via phone, post, email and SMS for the direct provision of your care, as well as to provide information, advice, lifestyle tips and inspiration. This communication is designed to enhance your outcomes and awareness.

You will also be included on a list for notifications of our special events, presentations, and offers.

Please let us know if you would like to opt out these lists, or alternatively, unsubscribe directly from any emails you receive.

Other Admin Questions
What is your current occupational status?*
Name of Next of Kin / Emergency Contact:*
Their Contact #
Their Relationship to You
Do you have a guardian/carer that supports you?*

NoYes
What is their name?
Does someone else pay your account?*

NoYes
What is their name?
Their Contact #
Do you have private health insurance that covers Chiropractic care?*
Please Select Your Fund (or add your fund if not in our list):
Our experience is that most funds provide cover for ‘crisis’ care,
not true, proactive or preventative health care.

The insurance model is built around protecting risk, not maximising your health!

It's good to know up-front that our recommendations for care
will often exceed your health fund's annual limits.
Do you currently know any of these details for your cover? (select any that you DO know):

	Similar / Consistent	Improving	Getting Worse
And it is...

	Similar / Consistent	Improving	Getting Worse
And it is...

	Heavy Physical Labour	Sustatined Postures / Positions	Awkward Postures / Positions	Repetitive Movements
Work Requires:

Your expectations, goals and hopes for how we might help you...

PLEASE TELL US WHAT YOU WOULD LIKE TO GET FROM YOUR EXPERIENCE HERE
Please help me:*

Improve my CURRENT CHALLENGESImprove my CURRENT CHALLENGES then explore further wellness optionsCOMPREHENSIVE health and wellness care for: MYSELFCOMPREHENSIVE health and wellness care for: MYSELF & MY FAMILY
I would like help improving my (our) - please select all that apply:
When I achieve or regain my health / quality of life, the most positive improvement I expect to see will be:
We assess your progress regularly, but what indicators will help YOU KNOW that your goals are being met?
Is there anything else which may help to better understand you which has not been discussed so far?

NoOther
Brilliant!!

THANK YOU...
we understand how detailed this questionnaire is!
Please tick to acknowledge the following:*

To the best of my knowledge, the statements above are a true and accurate historyI consent to a professional and complete examination (which involves physical touch) and I am aware that my chiropractor may require xrays to be taken.I understand that any fee for service rendered is due at the time of service and cannot be deferred to a later date
Electronically signed on this date:

DayMonthYear
Date
By (please re-enter your full legal name)
Please Note: We choose to not compromise with YOUR HEALTH or OUR REPUTATION.

As such, our standard policy is that only specific circumstances will lead to adjustments being performed before we have carefully analyse your history, examination findings and x-ray results (if they are required).

We begin your care after we have presented our findings to you - usually on a subsequent (2nd) visit.
Should be Empty:

	0	1	2	3	4	5	6	7	8	9	10
At Home
At Work or Study
At Play!

	1	2	3	4	5	6	7	8	9	10
Eating Habits
Exercise Habits
Sleep
Mindset
General Wellbeing

	Don't consume	Special Occasions	Rarely/Monthly	Few per month	At least weekly	Few per week	Every day	Multiple per day
Alcohol
Tea/Coffee
Fried Foods
Artificial Sweeteners
Soft Drink
Energy Drinks
Diet Foods, Drinks & Products
Dairy
Refined Sugar (foods containing)
Margarine
Grain-based foods (bread, pasta, cereal, flour, rice, oats, soy, corn etc.)
Canned/Frozen Vegetables
Smoking/Tobacco
Organic or Locally-sourced Foods
Grass-fed Meats
Fish
Fruit
Fresh, Raw, Steamed Vegetables
Colourful or "leafy" vegetable/salad matter
Fermented Foods (sauerkraut, kefir etc)
Offal / Marrow
Bone Broth

	Yes	No	Not Sure - How do I judge 'high quality'
Fish Oil
Vitamin D
Probiotics
Phytonutrient/Multi-mineral 'green' drink

	No	Yes (in the past)	Yes (currently)
Massage
Naturopath
Homeopath
Chinese Medicine
Acupunture / Dry Needling
Bowen
Personal Trainer
Nutritionist
Life Coach / Personal Coach
Psychologist / Counsellor / Therapist
Spiritual Guru / Religious Minister
Other

CONFIDENTIAL NEW CLIENT INTAKE FORM

Please let us know how you found us!

Personal Info

To help you, we need to know...

Stress Survey

Tell us about your Family and how you spend your time...

All things Biochemistry!

Tell us about the health professionals you consult...

Other Critical Information

Your expectations, goals and hopes for how we might help you...

	No	Yes (prescribed)	Yes (off the shelf)	Have had prescribed, but no longer wear
Rigid (Hard) Orthotics
Functional (Soft) Orthotics
Heel Lifts
Special Shoes