Opse Health - Baseline Intake Application

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.)
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Mobile Number

Area CodePhone Number
Email Address
example@example.com
Age Range
Primary Location
Preferred Contact Method
What are you applying for?

Other (please specify)
Why now? (Tick up to 3 reasons)

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)

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0 is Not disappointed, 10 is Extremely disappointed
Do you understand Opse is primarily face-to-face in Brisbane?
In the next 12 months, how much will you be away from Brisbane?
Travel pattern (tick all that apply)
What days/times are you realistically available? (Tick all that apply)
In the last 12 months, how often have you cancelled appointments last-minute?
Which statement best fits you? (Investment fit)
Comfort with annual investment in preventive medicine
If accepted, are you open to ongoing Governance after the initial program if clinically appropriate?
Importance: Making meaningful health changes in the next 90 days is…

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0 is Not important, 10 is Extremely important
Confidence: I’m confident I can follow a plan consistently for 90 days…

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0 is Not confident, 10 is Extremely confident
Priority: I can realistically prioritise this despite life/work…

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0 is Not a priority, 10 is Top priority
Which best describes your current stage?
When you’ve had a plan before, what usually happens?
Do you understand that screening can cause false positives/incidental findings and may lead to further tests?
If a result is abnormal, I am willing to follow recommended next steps
How do you prefer decisions to be made?
How do you handle uncertainty?
Health Snapshot – Do you have any of the following? (Tick any that apply)

Other (please specify)
If you selected 'Other' above, please specify:
Current medications (or attach a photo/list)
Smoking/vaping status
Alcohol use
Exercise currently
Main barrier to execution right now (choose one)
Family history (parents/siblings) – tick any that apply

Other (please specify)
If family history includes cancer, please specify type:
Family history – notes / ages (if known)
Upload recent pathology (PDF)

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Upload imaging reports (PDF)

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Upload specialist letters (PDF)

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I understand Opse is fully private.
I understand diagnostics are offsite and paid direct.
I understand screening is discussed with consent and escalation pathways.
I understand Opse is not urgent care.
I understand acceptance is based on fit and capacity.
If accepted, I will receive an invitation to schedule.
What made you choose Opse instead of a standard check-up?
Should be Empty:

Opse Health Baseline Intake Application