• ADULT MEMBER INTAKE

    CONFIDENTIAL details about current/past health, stress-load & desired outcomes/goals

  • Welcome to Optimal Life Health Centres in Noosa

    Please complete this form in as much detail as you can
    - the more detail you provide, the better we are able to help you...

  • How to complete this form:

    Questions that must be completed have a red asterisk* following a question.
    All other questions are optional; answering them helps us understand how we can best help you!

    Move through the form by clicking on the white arrow on a section header (like 'How have you found us' below). Next and Back buttons will appear once each page is complete.

  • Your Privacy:

    Optimal Life Health Centres have a Privacy Policy available here in which we have adopted the National Privacy Principles (NPPs) contained in the Commonwealth Privacy Act 1988 (the Privacy Act). Please read our policy as it outlines information such as: 

    • What is your personal information and why we collect it.
    • A definition of sensitive information
    • Third parties and your privacy
    • Disclosure, security and access to your personal information
    • Maintaining the quality of your personal information, and
    • How to proceed if you have any Complaints or Enquiries
  • Please acknowledge the following:
    • How Did You Find Us? 

    • Friends, family-members, colleagues or another health professional have often referred or recommended our services to new people such as yourself.


    • That's great for us to know! We aim for your care with us to exceed your expectations no matter how you are first introduced to our business. How did you find us?

    • Our mission is to grow a vibrant, extraordinarily healthy community of people actively engaged in seeking their optimal life. And we can't do this without more people understanding what we do!

      We welcome YOUR referrals (loved ones, friends and colleagues) and are deeply grateful if you choose to introduce them to us.

      The potential benefits of our care can be different for different people. It is SO much more than helping sore necks and backs!

    • If you object to either of the following, please OPT OUT by checking the appropriate box (otherwise LEAVE BLANK):

  • Personal Information

    Admin basics to open a member's file for you...

  • Please enter your FULL LEGAL NAME (if you have a preferred name we'll get that shortly!)

  • Title:
  • Current Date (for age calculation)
     - -
  • Do you have a different Postal address?*
  • State:*

  • OPTIONAL: Provide us with a photo so we recognise you when you arrive!
    (Either take a photo below if your device has an inbuilt camera, or upload one you like better!)

  • Take Photo here...
  • Upload a File
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    • How Do We Contact You? 

    • Contact Phone Numbers:
      We'd prefer at least two numbers - a primary number and a backup if possible!

      If you DON'T have a mobile, enter your landline number (with area code ie. 07 xxxx xxxx) in the "Mobile" box (a number must be entered in this box to proceed)

    • Format: 0000 000-000.
    • Format: (00) 0000-0000.
    • Format: (00) 0000-0000.

    • Select your preferences for how you would like us to contact you:
      (you can select more than one)

    • We will use your preferred means of contact whenever possible, yet we may use any of these methods, as well as post. Tell us in person if you DO NOT want contact by any particular method.

      We send email relevant to your chiropractic care
      ...      but no-one wants email 'spam'!

      Please tell us if you don't welcome the type of content or frequency of email from us. If we don't know you've un-subscribed, you may miss vital info from us!

    • When is usually the best time of day for us to contact you?
      (you can select more than one)

    • Their Relationship to You*
    • Format: (0000) 000-000.
    • Are you supported by a guardian or carer?*
    • Does someone else pay your account?*
    • Format: (0000) 000-000.
    • Basic Details about Family, Work & Insurance 

    • Details about Private Insurance...

    • Do you have private health insurance that covers Chiropractic care?*

    • Private insurance 'extras' packages don't tend to provide enough rebate for true
      ongoing / proactive / preventative strategies aimed at maximising health & wellbeing.

      Our recommendations ARE about being proactive, not reactive! 
      It may be that our suggested care-plans exceed your health fund's annual limits.

    • Select Your Insurance Provider:*

    • Some basics about your relationship and/or family...

    • When did your (or their)last period finish?
       - -
      2 digit day, 2 digit month, 4 digit year
    • When did their last period finish (if known)?
       - -
      2 digit day, 2 digit month, 4 digit year
    • What are your kid's names (even if they're adults!) and have they had chiropractic care?

    • Some basics about your work or daily activity...

    • Occupational Status?*
    • Completing When?
       - -
      2 digit day, 2 digit month, 4 digit year
    • Select or Add your Industry:*
    • Work (daily activity) can be a primary source of stress. Select any options below if they affect you in any of your roles, volunteering, jobs or studies:*

    • Hidden Section for Background Colour 
    • Roster / routine variation?
    • Because you sit or drive for long periods, do you take regular breaks?
    • Is your workspace ergonomic (good chair, desk or computer at right height)?
    • Is what you have described above typical of your past working life?*
    • List any significant previous occupations if they differ from above:
    • Because you're not currently working, please briefly describe significantoccupations you may have previously had:
    • Hidden Section for Background Colour 

    • Thanks, that's the Admin done! Click NEXT (below)...

  • Why do you need our Help!

    PLUS...your past experience (if any) with Chiropractic!

  • Some people do, and we're happy to respond to any questions up-front!

    Rest assured: we will address any concerns you may have!
    It's important to us that you're confident and comfortable with who we are & what we do!

  • Your experience or history with Chiropractic care...

  • Have you seen a Chiropractor before?*
  • Are you still seeing them?

  • Date of last visit (approx):*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Chiropractor's name and contact details (if you know them)...
  • Which option best describes the chiropractic you have experienced so far?*
  • Can you contact them to request your recent records and/or X-ray reports/images?*

  • If you can make contact to request this information, it can streamline our first visit with you and may make it easier for us to provide initial care straight away.

  • If they will accept your verbal authority, have them send records to:

    healthier@optimallife.net.au

    If your chiropractor requests a Records Release Authority form:

    download this form here.

    Complete it and scan/email or fax it to them.

    •  
    • SATISFACTION LEVEL:My chiropractic care in the past...
    • How FREQUENTLY have you visited achiropractor? (now and in the past)
    • Have chiropractors used any of the following technologies in your care before now?
    •  
    • How Can We Help You? 

    • People often seek CHIROPRACTIC help when they've got health challenges:
      symptoms, concerns, complaints, discomfort or dysfunction.

      We definitely help people like that!

      CHIROPRACTIC can also be used as a preventative, proactive option - used regularly it has great value: enhancing your health and wellbeing;
      helping you toward living a more       vibrant, extraordinary life...

    • So, please choose one option below...*

    • Great!

      The following information will help us design a specific
      program to help you move toward your
      'Optimal Life'

    • Are you seeking help just for yourself right now, or for your family as well?*
    • This question modifies how much detail is requested thru the rest of this form:*
    • Health Challenges or Concerns: 

    • In a few words describe the location and 'problem' in the first box below,
      then use the following questions to 'flesh out' what is going on for you. 

      If you have more than one challenge or concern, provide detail for each separately.
      This form can accept up to 4 separate health concerns.

    • Health Challenge #1 (most significant):*
    • Does this Health Challenge cause you discomfort (pain)
    • How intense or severe is your pain:*

    • 0 = No Pain / 10 Worst imaginable

    • Tell us more about the characteristics of your pain:*
    • Description (what does it feel like?):
    • Another health challenge?*
    • Health Challenge #2 (next most significant):*
    • Does this Health Challenge cause you discomfort (pain)
    • How intense or severe is your pain:*

    • 0 = No Pain / 10 Worst imaginable

    • Tell us more about the characteristics of your pain:*
    • Description (what does it feel like?):
    • Another health challenge?*
    • Health Challenge #3 (next most significant):*
    • Does this Health Challenge cause you discomfort (pain)
    • How intense or severe is your pain:*

    • 0 = No Pain / 10 Worst imaginable

    • Tell us more about the characteristics of your pain:*
    • Description (what does it feel like?):
    • Another health challenge?*
    • Health Challenge #4 (next most significant):*
    • Does this Health Challenge cause you discomfort (pain)
    • How intense or severe is your pain:*

    • 0 = No Pain / 10 Worst imaginable

    • Tell us more about the characteristics of your pain:*
    • Description (what does it feel like?):
    • Another health challenge? Select YES for more provide details*

    • For any further health challenges, download this PDF.

      Fill out and save this fillible PDF document.
      (1 PDF per additional challenge).

      Use button on right to attach 1 or more PDFs once complete.

    • Upload File Here
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    • Things that aggravate or relieve | IMPACT on my life 
    • Does anything bring on or worsen these health challenges:*
    • Has anything relieved / improved / alleviated your health challenges/symptoms:*
    • How is this affecting your life?Does it prevent or reduce your participation in particular activities?*
    • *



    • Things like: Eating differently? Less alcohol or drugs? Beginning to meditate? Reducing or stopping strenuous or destructive activities? More exercise / movement, sleep / rest, yoga / stretching etc.

    • Who else have you seen about these concerns? 
    • Have you received advice or consulted any other health professionals about these issues?*
    • *
    • Has any of this care or advice helped you?*

    • Thanks! Click Next (below) to outline your current health & areas of stress in your life...

  • Stress Survey & Health Self-ratings!

    • This is the most important part of this form! 

    • People tend to think of stress as just "worry."

      In and of itself, stress is neither good nor bad - it causes problems if you can't adapt or dissipate the stress effectively - leading to "build-up".

      There are 3 broad categories of potential stress (below) that can cause or contribute to health problems either by themselves or together.
      They may affect how we function, including how we heal.

      This is section is critically important!

      In each category below, select options that have occured / do occur in your life.

      NOTE: What is stressful for one person, may not be for another.
      These lists are only POTENTIAL stressors that MAY (or may not) be part of your solution.

    • Did any of these physically stressful events result in:
      Rows
    • Fora all motor vehicle accidents tick all relevant boxes below that describe the accidents:*
    • Are any of the following currently causing you significant stress?
    • Health Self-Ratings 

    • Please RATE yourself so we know where you think you're at...

    • Please think for a moment about the quality of your health and life right now.

      If   0  =  DEAD AND  100 =  Ideal Life  (Vibrant, Healthy, Fun, Happy, Creative, Passionate, Fulfilled...)

    • Rate your general quality of your life right now...*
    • How would you rate your Physical Health*
    • How would you rate your Mindset / Mental Health*
    • How would you rate your Food Intake / Eating Habits*
    • How many glasses of PURE WATER do you drink in the average day? (1 glass = 250mL)*
      Rows

    • DO NOT include tea, coffee, cordial, soft drink or alcohol!

    • I would classify myusual food intake as:
    • Do you skip meals?
    • Have you experimented with / are you now using a program of intermittent fasting?
    • Are you currently using some form of diet or eating program to achieve weightloss?
    • How often do you consume the following...
      Rows
    • Sliders with calculated result
    • How often do you consume the following...
      Rows
    • How would you rate your Movement / Exercise Habits*
    • Select the types of movement / exercise you currently engage in.(Include significant or long-term things you have done in the past)*
    • About your Team Sport...
    • How would you rate your Sleep?*
    • Sleep Experiences(select all that are current or regular)
    • Do you wake feeling:

    • Thanks! Click NEXT (below) to outline your Medical History...

  • General Medical History & Systems Review

  • Do you have difficulty with any of the following?
  • Have you ever been told you have Scoliosis?
  • Do you have good bowel / bladder control?*
    • "Systems Review" 

    • Please review each of the following body areas.
      Select any options that are CURRENT or have RECENTLY been affecting you. 

      These signals or symptoms can help us identify possible reasons/causes
      for underlying, developing or current problems. 

    • Head Region
    • Heart Related
    • Lungs / Respiratory
    • Immune
    • Digestive
    • Nervous System, Brain, Mental Health
    • Senses
    • Metabolic

    • Because you selected 'Trans/Intersex', please answer relevant questions
      as they relate to both male and female physiology.

    • For Men
    • For Women


    • Have you ever miscarried or still-birthed?

    • We understand this is a very sensitive question.
      Don't answer it if you feel uncomfortable doing so.

    • Medical History 

    • Major Illnesses or Diagnoses:

    • Do you have (or have you been diagnosed with) any ongoing health disorder or major illness?*

    • We're interested in your health and wellbeing,
      AND also that of your family and loved ones.

    • Are any of your friends / family suffering from these major illnesses or other health challenges?

    • Surgery or Hospital Stays:

    • Have you had surgeries or hospital stays for any reason?*
    • Please outline any surgeries or hospital stays:

    • Medical Images or Scans (X-Rays etc):

    • Have you ever had x-rays or other medical imaging / scans taken?*
    • List any details you recall, particularly any imaging of your spine. (Don't know/remember? Leave blank)

    • Over-the-Counter or Prescribed Medication Use:

    • Please list any drugs or medication you are taking or have taken in the past 6 months (one medication at a time)*
    • A little more Biochemistry! 

    • Supplements & Vitamins:

    • Do you currently consume (on a daily basis) any high quality forms of the following?*
      Rows
    • Please list all nutritional supplements, vitamins, herbal tinctures, homeopathic remedies you presently take and why:

    • Alcohol & Tobacco Use:

    • Do you currently smoke, chew tobacco or use nicotine gums or patches?
    • Do you drink alcohol?*

    • Recreational Drug-use:


    • Please remember, this form is CONFIDENTIAL!

      We ask questions related to both legal and recreational drug-use because ALL drugs alter your physiology and it is useful for us to know as we provide care and assess your progress.

    • Thanks! Click NEXT (below) to outline any other
      health professionals you regularly see...

  • Your other health professionals...

    We can help you better when we know who else is on your health team!

  • Two very different approaches toward "health" exist:

    HEALTH-care   (helping you 'always raise the bar' - to grow, learn & improve function)
    CRISIS-care      (reacting to illness/emergency or keeping you alive!)

    One is "proactive / prevention / wellness" while the other is "sickness / treatment."

    Both are IMPORTANT & VALUABLE in different circumstances.

  • Do you have a MAIN or REGULAR doctor / health professional who is your "go-to" or first point of contact for health questions or concerns?*
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  • Format: (00) 0000-0000.
  • Their profession:

  • Date of Last Visit?
     - -
    2 digit day, 2 digit month, 4 digit year

    • Proactive Health Team: 

    • Choosing to see a range of health providers consistently is part of achieving true HEALTH-care.
      (We call this "developing a PROACTIVE HEALTH TEAM")       

      Often these people will see you whether or not you have symptoms, to assess for dysfunction before it becomes a crisis, to give ADVICE and help IMPROVE your 'self-care' practices!

    • Do you / have you used any of these professionals in recent times:
      Rows
    • Dental Health / Hygiene: 
    • Do you brush teeth at least twice / day *
    • Do you floss regularly?
    • Do you visit the Dentist at least every 6 months for a check-up / clean?

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    • Do any of the following apply (or have they applied) for you:

    • Brilliant! Click NEXT (below) for final questions which complete your comprehensive profile...

    • Brilliant - You're done! Click NEXT to complete and sign this form...

  • Final Detail for Comprehensive Health Profile

    Important details to complete our understanding of "who" you are!
  • Firstly, are all of your immediate family members still alive?(parents, siblings, children)*
  • We understand this may be sad or painful. If you are willing, please let us know who has passed?

    • What do you do for recreation... 
    • What do you LIKE to do? What do you do for FUN? What MOTIVATES you?*
    • Empowering Activities... 
    • Many people engage in empowering activities like those listed below.Which (if any) are important in your life...*
    • Your Birth: 

    • For many people, their mum's health while pregnant OR the birth process itself can result is a great amount of stress, and may be the first underlying cause of health problems...

    • While pregnant with you, was your mother:
    • While pregnant with you, was your mother taking anymedication or drugs (including illicit drugs or alcohol)
    • What interventions were used (if any) in your birth?
    • Did you have a difficult birth, or were there complications?

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    • Walking / Your Feet 
    • Have you ever been told you have:*
    • Have you ever been prescribed, or do you currently wear:
      Rows
    • Do you usually wallk around in...

    • Brilliant - You're done! Click NEXT to complete and sign this form...

  • Your goals for how we help you...

    WHAT YOU WOULD LIKE TO GET FROM YOUR EXPERIENCE HERE?
  • I would like help improving... (Please select all that apply)*

  • One final question...


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  • Please tick to acknowledge the following:*
  • Electronically signed on this date:*
     - -
    2 digit day, 2 digit month, 4 digit year
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