• 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.

    • and enter today's date:*
       / /
      2 digit day, 2 digit month, 4 digit year

  • 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. 


  • Great!

    We do (of course!) welcome you WARMLY.
    We care for every person as a VIP referral ANYWAY!

  • When was this?
     / /
    2 digit day, 2 digit month, 4 digit year

  • 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:

  • 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:*
    • Important Information 
    • Your Addresses 
    • Home Address:*
    • Different Postal?*

    • Postal Address:

    • How Do We Contact You? 
    • Format: 0000 000-000.
    • Format: (00) 0000-0000.
    • Format: (00) 0000-0000.
    • 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?*
    • Format: (0000) 000-000.
    • Their Relationship to You
    • Do you have a guardian/carer that supports you?*
    • Does someone else pay your account?*
    • Format: (0000) 000-000.
    • 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):

  • To help you, we need to know...

    • Your experience with Chiropractic... 

    • As Chiropractic is the primary 'vehicle' through which we help you, please let us know about your history or experience with chiropractic care.


    • We promise we will address these concerns with you before we proceed, and make sure you are confident and comfortable with who we are and what we do!

    • Have you seen a Chiropractor before?*
    • Please provide us with their details (if you can) - this allows multiple entries if you have seen more than one!
    • Are you still seeing them?*

    • Date of last vist (approx):
       / /
      2 digit day, 2 digit month, 4 digit year
    • Can you make contact to request your recent records and/or X-ray reports/images?*
    • Did you seek Chiropractic care in the past for:

    • OPTIONAL: Some other questions to help us understand your experience with chiropractic...

    • Were you impressed by your experience?
      Rows
    • Was your Examination thorough?
    • Were you given home care / exercises or recommended supplementation?
    • Please select any of the frequencies of care you've had (now / past)
    • Have chiropractors you have seen used or needed:
    • What Can We Help You With? 

    • This section helps us identify what has brought you in to see us.

    • The critical question... Are you:*

    • Great!

      Proceed to the next page.

      Let's get more info to help us help you toward your 'Optimal Life'

    • Health Concerns / Challenges / Complaints / Discomfort: 

    • Please list in a few words ALL of your health concerns in order of their importance to you (one per line!)

    • Health Challenge #1 (most significant to you):*
    • 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:*
    • Another health challenge? Select YES to provide details*
    • Health Challenge #2 (next most significant to you):*
    • 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:*
    • Another health challenge? Select YES to provide details*
    • Health Challenge #3 (next most significant to you):*
    • 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:*
    • Another health challenge? Select YES to provide details*
    • Health Challenge #4 (next most significant to you):*
    • 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:*
    • Another health challenge? Select YES for more provide details*
    • Upload a File
      Cancelof
    • Modifying factors and Impact on YOUR life 
    • Does anything aggravate / begin / make these health challenges worse:*
    • Has anything relieved or improved your health challenges/symptoms:*
    • And the essential question! Are these health challenges/symptoms interfering with any of the following:*
    • *
    • Your perspectives, beliefs or understanding about them... 

    • If you have more than one health challenges, do you feel they are:



    • Who else have you consulted or asked about these concerns? 
    • Have you seen any other doctors or health professionals for (or consulted anyone who may have had personal experience with) these health challenges:*
    • Please tell us who you have consulted so far*
    • Has any of this care or advice helped you?*

    • Great! Now we have that detail, please go to the next page to tell us more about the stresses in your life...

  • Stress Survey

    Stress occurs anytime the body is required to adapt to an event and alter its function. Stress can be both good and bad, and what is stressful for one person, may not be for another. Oftentimes, the build-up of life's stresses can lead to health problems and influence our ability to heal
  • Reflect on your quality of health and life right now: if 100 = ideal, most abundant, vibrant, healthy, excited, fun, happy, creative, passionate, fulfilled and 0 = 'dead', how would you rate your life right now?*
  • On a scale of 0 (no stress) - 10 (very stressed), please grade your current levels of stress in each of the following areas:*
    Rows

  • Please select ANY and ALL stresses (you have ever had)
    in each of the following three categories:

  • PHYSICAL:*
  • As a result of any of these injuries or accidents, did you, were you or have you ever been:
    Rows
  • For accidents involving motor vehicles were you:
    Rows
  • BIOCHEMICAL:*
  • MENTAL-EMOTIONAL:*
    • Self-Ratings: 
    • How would you rate your Physical Health*
    • Rows
    • How would you rate your Mental Health*
    • Rows
    • On a scale of 1 (very poor) - 10 (excellent), please self-rate your:*
      Rows

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

    Details about your relationships, fun, rest and how you earn a living also paint a detailed picture for me of your lifestyle...
    • Tell us some basics about your family... 
    • Date of your (or their) last menstral period (if known)
       - -
      2 digit day, 2 digit month, 4 digit year
    • Parenting can be stressful! Please introduce us to your kids:
    • Are all of your immediate family members (parents, siblings, children and grandparents) still alive?*

    • Many health concerns can result from patterns of lifestyle, belief and behaviour that are often similar in families. 


    • Tell us more about your work or daily activity... 
    • When do you finish your study?
       - -
      2 digit day, 2 digit month, 4 digit year
    • How is your work stuctured?
      Rows
    • Do you spend much or most of your day:*
    • Does your work or study require:
      Rows
    • If you sit or drive consistently or for long periods, do you take regular breaks?
    • Is your workspace ergonomic (good chair, desk or computer at right height)?

    • Are these characteristics typical of your past working life?
    • List any significant previous occupations if they differ from above:
    • What do you do for recreation... 
    • What motivates you and brings you pleasure? What do you LIKE to do?*
    • Have you in the past or do you continue to partake in any of the following:
    • Do you have physically demanding hobbies:
    • Do you play team sports?*
    • Configurable list
    • Tell us about your sleep... 
    • Questions about the quality of your sleep - select any and all that are relevant for you:
    • Do you wake feeling:*
    • Empowering Activities... 
    • Do you regularly do any of the following - select any and all that are relevant for you:*

  • All things Biochemistry!

    The chemistry of our cells affects everything we do in life. Let's get some detail...

  • Your Practices around FOOD and EATING HABITS (menu/diet):

  • The meals I usually eat would be classified as:
  • Are you currently on a menu (diet) designed to control/lose weight?*
  • Are you using a program of intermittent fasting?
  • Do you skip meals?
    • What do you routinely consume? 
    • Please grade how often you consume each of the following...*
      Rows
    • 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:
    • Over-the-Counter, Prescribed or Illicit Drug Use... 
    • Please list any drugs or medication you are taking or have taken in the past 6 months (one medication at a time)*

  • Tell us about the health professionals you consult...

    It's important for your health team to be able to communicate and keep updated about what we are all doing so we can integrate your care and provide the best approach at all times!

  • Our perspective is that there is a difference between true HEALTH care (designed to help you function at ever-increasing levels) and SICK care or CRISIS care (designed to extend your life on this planet and respond to emergency).

    Both are REALLY vital, valuable approaches.

    Sick-care serves an important purpose and the skills of these doctors and professionals is gratefully appreciated when needed, but they don't exist to help you live a vibrant, extraordinary life. In fact, applying sick-care to healthy people is a contradiction - and when we do, we get sick, dying or dead people!

  • Do you have a primary HEALTH CARE provider that you visit or consult with regularly?*

  • Format: (00) 0000-0000.
  • Do you have, or consult with a CRISIS-CARE expert? (family doctor / general practitioner)*

  • Format: (00) 0000-0000.
  • Date of Last Visit?
     - -
    2 digit day, 2 digit month, 4 digit year
  • Are you still receiving treatment?
    • Dental Health & Hygiene: 
    • Do you brush teeth at least twice / day *
    • Do you floss regularly?
    • How often do you visit the Dentist?


    • Proactive Health Team: 

    • Choosing to develop a PROACTIVE HEALTH TEAM to help you live the best life possible is a great choice!

    • Please tell us if you have consulted, or do still consult with any of these professionals:*
      Rows

  • Other Critical Information

    These questions provide information about your illness history or interventions you may have had (that we have not already covered).
  • Do you have experience difficulty with any of the following?
  • Have you ever been diagnosed with Scoliosis?
  • Do you have good bowel / bladder control?
    • Your Birth: 
    • While pregnant with you, was your mother:
    • While pregnant with you, was your mother taking any medication or drugs (including illicit drugs or alcohol)
    • Did you have a difficult birth, or were there complications?

    • What interventions were used (if any) in your birth?
    • Surgery or Hospital 
    • Have you had any surgery or hospital stays for reason?*
    • Please outline any surgeries or hospital stays:
    • Diagnostic Imaging 
    • Have you ever had x-rays or other medical imaging / scans taken?*
    • Please list all detail you can, particularly any imaging of your spine. If you don't know/remember, leave blank*

    • Walking / Your Feet 
    • Have you ever been prescribed, or do you currently wear:
      Rows
    • Signals or Symptoms of Potential Underlying Dysfunction 

    • These signals (symptoms) may indicate underlying or developing dysfunction.

      Please review each of the following lists and select all options that are either CURRENT or have affected you in the RECENT PAST. 

       

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

    • Because you have selected 'Other' for your SEX, please answer relevant questions as they relate to both male and female physiology.

    • For Men
    • For Women


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


    • Did you experience any of the following associated with your delivery (ies)?
      Rows
    • Major Diagnoses 
    • Do you have (or have you been diagnosed with) any ongoing health disorder or major illness?

    • Our health centre is interested not only in your health and wellbeing, and also that of your family and loved ones.

    • Are any of your friends or family suffering from any of the above issues?

  • 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:*
  • I would like help improving my (our) - please select all that apply:

  • Brilliant!!

    THANK YOU...
    we understand how detailed this questionnaire is!

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

  • 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: