Opse Health Baseline Intake Application
Complete this form to help us confirm program fit, screen for safety, and allocate clinician capacity for the Baseline program.
Safety Screening: Are you currently experiencing any of the following? (Tick any that apply.)
Chest pain/pressure, shortness of breath at rest, fainting, sudden weakness/numbness, or new confusion
Severe headache
Unintentional weight loss with night sweats or persistent fever
Black stools or vomiting blood
Suicidal thoughts or risk of harm to self/others
None of the above
Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Mobile Number
*
-
Area Code
Phone Number
Email Address
*
example@example.com
Age Range
*
Please Select
18–29
30–39
40–49
50–59
60+
Primary Location
*
Please Select
Brisbane
Gold Coast
Sunshine Coast
Regional QLD
Other (please specify)
Preferred Contact Method
*
Phone call
SMS/Text
Email
What are you applying for?
*
Baseline Program (comprehensive health screening)
Second opinion/consult only
Other (please specify)
Why now? (Tick up to 3 reasons)
Recent health scare
Family history concern
Want to be proactive
Doctor recommended
Preparing for a life event (e.g. travel, job change)
Other (please specify)
If you selected 'Other' above, please specify:
In one sentence, what would ‘success in 90 days’ look like for you?
How disappointed would you be if nothing changed in the next 12 months? (0–10)
Not disappointed
0
1
2
3
4
5
6
7
8
9
Extremely disappointed
10
0 is Not disappointed, 10 is Extremely disappointed
Do you understand Opse is primarily face-to-face in Brisbane?
*
Please Select
Yes
No
Unsure
In the next 12 months, how much will you be away from Brisbane?
*
Please Select
Not at all
Less than 2 weeks
2–4 weeks
More than 1 month
Travel pattern (tick all that apply)
Frequent business travel
Interstate travel
International travel
None of the above
What days/times are you realistically available? (Tick all that apply)
Weekdays – mornings
Weekdays – afternoons
Weekdays – evenings
Weekends
In the last 12 months, how often have you cancelled appointments last-minute?
Please Select
Never
Once
2–3 times
More than 3 times
Which statement best fits you? (Investment fit)
*
Please Select
Ready to invest for comprehensive health
Need to discuss/consider further
Not sure if this is the right time
Comfort with annual investment in preventive medicine
Please Select
Comfortable with private fees
Prefer to discuss options
Not sure
If accepted, are you open to ongoing Governance after the initial program if clinically appropriate?
Please Select
Yes
No
Unsure
Importance: Making meaningful health changes in the next 90 days is…
Not important
0
1
2
3
4
5
6
7
8
9
Extremely important
10
0 is Not important, 10 is Extremely important
Confidence: I’m confident I can follow a plan consistently for 90 days…
Not confident
0
1
2
3
4
5
6
7
8
9
Extremely confident
10
0 is Not confident, 10 is Extremely confident
Priority: I can realistically prioritise this despite life/work…
Not a priority
0
1
2
3
4
5
6
7
8
9
Top priority
10
0 is Not a priority, 10 is Top priority
Which best describes your current stage?
Please Select
Just starting to think about my health
Already making changes
Looking for accountability/support
When you’ve had a plan before, what usually happens?
Please Select
I follow it fully
I start strong, then lose momentum
I struggle to start
Do you understand that screening can cause false positives/incidental findings and may lead to further tests?
Please Select
Yes, I understand
No, please explain
If a result is abnormal, I am willing to follow recommended next steps
Please Select
Yes
No
Depends on circumstance
How do you prefer decisions to be made?
Please Select
Clinician-led
Shared decision-making
I prefer to decide myself
How do you handle uncertainty?
Please Select
I’m comfortable with uncertainty
I need clear answers
It depends on the situation
Health Snapshot – Do you have any of the following? (Tick any that apply)
High blood pressure
High cholesterol
Diabetes
Heart disease
Cancer (current or past)
None
Other (please specify)
If you selected 'Other' above, please specify:
Current medications (or attach a photo/list)
Smoking/vaping status
Please Select
Never
Former
Current
Alcohol use
Please Select
None
Occasional
Regular
Exercise currently
Please Select
None
1–2 times/week
3–5 times/week
Daily
Main barrier to execution right now (choose one)
Please Select
Time
Motivation
Resources
Support
Other
Family history (parents/siblings) – tick any that apply
Heart disease
Stroke
Diabetes
Cancer
None
Adopted / Unknown Family History
Other (please specify)
If family history includes cancer, please specify type:
Family history – notes / ages (if known)
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I understand Opse is fully private.
*
I confirm
I understand diagnostics are offsite and paid direct.
*
I confirm
I understand screening is discussed with consent and escalation pathways.
*
I confirm
I understand Opse is not urgent care.
*
I confirm
I understand acceptance is based on fit and capacity.
*
I confirm
If accepted, I will receive an invitation to schedule.
*
I confirm
What made you choose Opse instead of a standard check-up?
Submit Application
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