Optimal Life New Client (Adult)

PRIVACY POLICY
Privacy Statement: Please read Optimal Life Health Centres' Privacy Policy available here. It adopts the National Privacy Principles (NPPs) contained within the Commonwealth Privacy Act 1988 (as amended) and outlines information such as:
- What your personal information is and why we collect it.
- Sensitive information, third parties and your privacy
- Disclosure, security and access to your personal information
- Maintaining the quality of your personal information, and
- Complaint or enquiries processes, should they be needed.
PRIVACY STATEMENT ACCEPTANCE:

I am aware why my personal information is collected and how it may be used or disclosed. I can choose what information I provide, but withholding or falsifying information might act against my best interests. I can access my personal information and records of care on request and correct information I believe is inaccurate; if in exceptional circumstances, access is denied for legitimate purposes, reasons for this and possible remedies will be made available to me.
I have read the Optimal Life Privacy Policy and I:*

ACCEPT

HOW DID YOU FIND OUT ABOUT US?
You may have been recommended to us by a friend, family-member, colleague or another health professional...
Who recommended you to us?*

I wasn't referred directly. I found you by other means.Other
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 health centre. How did you find us?
Please select from this list:*
Our mission is to grow a vibrant, extraordinarily healthy community of people actively engaged in moving toward their optimal life.

We welcome the loved ones, friends and colleagues YOU refer to us and we are deeply grateful for your introductions.
The potential benefits of our care and advice are many. We offer SO much more than help for sore necks and backs!

CHOOSE THE BEST FORM FOR YOU
PLEASE NOTE: an email address is required to complete this form. If you do not have an email address, please call our office on 07 5474 9947 for an alternative.
Select your age to customise this form:*

AdultChild / Teen (2-16 years)Baby (up to 2 years old)Office Use Only
Are you local or visiting?*

I live locally or in the regionI'm visiting Noosa (temporarily - holiday etc.)I'm visiting Noosa (and I come regularly)
Please enter your FULL LEGAL NAME:
Please enter your baby's FULL LEGAL NAME:
Title:*
First:*
Last:*
Name of parent/guardian completing this form*

First NameLast Name
As this is for a person under-age, if a parent/guardian completes or supports completing this form, enter their name*

First NameLast Name
Please enter a parent's email (whoever is responsible for making appointments)
Please enter Mum or Dad's email (unless you're old enough to organise your own appointments and you want direct email contact from us)
E-mail Address:*
Email is critical for our communication with you
We send email relevant to your care in our health centre...however we don't want to 'spam' you!
Please advise us if content or frequency of our email is unsuitable. If we don't know you've unsubscribed, you may miss vital info from us!

Extra Admin Info...

We've already taken some details over the phone. Please give us these extra bits...
How do you want us to address you?*

First NameTitle-SurnameOther
Sex:*
Home Address

Street Address

Street Address Line 2

City or TownState (Add state if Intern'l)

Post CodeCountry
Different Postal address?*

NoYes
Postal Address*

Post Box or Alternate Mailing Address

Street Address Line 2

City or TownState (Add state if Intern'l)

Post CodeCountry
Emergency Contact:*
We're required to collect this. Sorry!
Their Relationship to You*
Their Contact #*
Relationship Status:*
Spouse/Partner's Name?*

Same as Emergency ContactOther

Contact Preferences
Preferred means of contact (you can select more than one)*
Best time of day to contact? (you can select more than one)*
We will attemt to use your preferred means of contact whenever possible, however if you DO NOT want contact by any particular method please tell us.

Do you have Kids?
Are you / your partner pregnant or do you have children?

Basic info about your family helps us understand your life more completely.
Do you have children?*
OPTIONAL: If you would like to, please share their name/s and age/s
Are they school-age, younger, or independent?
OPTIONAL: Have your kids ever seen a chiropractor?

YesNoWhy would I take my kids to the chiro?
Are you (or your partner) currently pregnant or trying to conceive?*
When did your (or their) last period finish?

DayMonthYear
Leave blank if unknown
Is your partner currently pregnant or trying to conceive?*
When did their last period finish (if known)?

DayMonthYear
Leave blank if unknown
Do you want help just for yourself right now, or for your family as well?*

I'd like your help just for myself right nowI want to start along with my kids straight awayI'd like your help just for myself right now, but I do want to bring in my kids soon

Private Insurance
Details about Private Insurance...
Do you have private insurance that covers Chiropractic care?*
Select Your Insurance Provider:*
Private insurance 'extras' packages don't tend to provide enough rebate for ongoing / proactive / preventative strategies aimed at maximising health & wellbeing. Our recommendations ARE about being proactive, not reactive! It's possible that our care-plans will exceed your health fund's annual limits. Your per-vist rebate is dependant on your fund and your extras package - we have no control over it.

Employment or Main Life Role
Work or Primary Role...
Occupational Status?*
I am:*
Your occupation / job / role?*
Employer/Business Name:
How long has this role or lifestyle been your norm?*
How long have you been in this work, role or situation?
Is your current role typical of your past working life?*

YesNoIn some roles, not in othersThis has been my only role / position / job
Other Significant Occupations:*

Current Life Snapshot
Rate your broader quality of life right now (ie. MORE than just your health)*
0 = DEAD
Your Best Possible Life = 100
(vibrant, healthy, fun, happy, creative, passionate, fulfilled)
Rate specifically your general health and wellbeing right now (out of 10)?*
Based on how you are currently functioning, do you feel your actual age, better or worse?*

My ageYounger (healthier)Lots Younger! (a LOT healthier)Older (less healthy)Much Older (a LOT less healthy)
How do YOU rate these specific areas of your health and wellbeing?

For each rating below, drag the slider (or click) to the position that you feel represents how you feel about the question right now (over the immediate past past week for most questions):

LEFT-most position = WORST | RIGHT-most position = BEST

This also gives us something to compare to as we re-assess your progress over time!
EXAMPLE: If you rate a particular area 70% over the last week, drag the slider like this:
How would you rate your Physical Health over the past week?*
LEFT - Worst possible Physical Health | Best possible Physical Health - RIGHT
How would you rate your Mindset/Mental Health over the past week?*
LEFT - Worst possible Mental Health | Best possible Mental Health - RIGHT
How energetic or 'vital' you have felt over the past week?*
LEFT - No enegy at all | Most energetic you could possibly feel - RIGHT
How would you rate your ability to concentrate over the past week?*
LEFT - No ability to concentrate | Best possible ability to concentrate - RIGHT
How has your mood has been over the past week?*
LEFT - Worst mood possible | Best mood possible - RIGHT
How strong has your immune system been over the LAST 3 MONTHS (resistance to coughs, colds/infections etc.)?*
LEFT - Worst immunity possible | Best immunity possible - RIGHT
Rate your food intake and/or eating habits over the past week*
LEFT - Worst food/eating habits possible | Best food/eating habits possible - RIGHT
Rate your movement or exercise habits over the past week*
LEFT - Worst movement possible | Best movement possible - RIGHT
How well have you slept over the past week?*
LEFT - Worst sleep possible | Best sleep possible - RIGHT

OUTCOMES

Health Goals you want to ACHIEVE with our help
What would you LIKE your health to be (out of 10)?*
How important is it to you (out of 10) to work toward better health and wellbeing?*
WHAT AREAS OF LIFE WOULD YOU LIKE TO SET SPECIFIC GOALS TO IMPROVE? (Please select all that apply)*

	Labour Time	Birth Weight	Birth Length	APGAR Scores
Birth Stats

	Yes	No	Percentile?
Gaining height and weight normally?

	SOLIDS	COWS MILK
Introduced to

Contributors to Ill-Health

This section is VERY IMPORTANT
Physical, Chemical, Mental or Emotional factors often underlie or contribute to dysfunction or health problems & can affect your ability to heal.

They can cause your body to react and then attempt to adapt. If your body is not flexible enough to adapt, or can't efficiently dissipate these effecs OR if they are maintained over time a build up may occur, become dominant and can overwhelm your body's control systems (this is what disease is).

For each category below, please select 3 or more of the major factors CURRENTLY AFFECTING, or which HAVE AFFECTED you in the past. If something important is not on our list, select 'Something Else' - the more detail we have in this area, the more accurate we can be in our recommendations.

These are POTENTIAL or POSSIBLE factors which may affect one person's function more than the next. One specific event / trauma may be a 'straw on the camel's back' triggering a symptom or disease, however commonly we find that the combined 'load' over time has 'primed' your body toward overwhelm. Many of these contributors result from our lifestyle choices and behaviours.
PHYSICAL: select 3 (or more)*
Something else:
Have you ever been involved in a motor vehicle accident (car/motorbike)?

NoYes - DriverYes - PassengerYes - Pedestrian
For motor vehicle accidents, select all characteristics that describe the accident/s:*
Further details:
BIO-CHEMICAL: select 3 (or more)*
Something else:
MENTAL-EMOTIONAL: select 3 (or more)*
Something else:
Impact of work or daily activity...

Your work (daily activity) can also potential impact your health and wellbeing. This can indeed be a primary issue, significantly affecting the outcomes you can expect.
Select any below that affect you in your work, volunteering, or study:*

Review of Body Systems
Review this list of general body systems dysfunction
Please select CURRENT or RECENT health history significant or relevant to you.
Systems Review: Head / Neck / Shoulders / Senses / Dental / Sinus / Jaw / Ears / Snoring*
Systems Review: Heart / Blood / Lungs / Breathing*
Systems Review: Immune / Skin / Mental / Emotional / Musculoskeletal / Balance / Numbness*
Systems Review: Digestion / Food / Eating / Blood Sugar / Weight / Metabolism*
Do you have problems with your bowel / bladder control?*

YesSometimesNo
Systems Review: Bowel | Bladder*
Because you have selected Trans or Intersex, please select whichever options are relevant from BOTH the Male and Female lists.
For Men
For Women

Medication, Supplements or Remedies
Please tick if you:

currently take any medications (prescribed or otherwise), or have done so in the last 6 months
Please list any drugs or medication you are taking or have taken in the past 6 months (one medication at a time)*
Do you use birth control medication?

NoOther
Please tick if you:

currently take supplements, vitamins, tinctures or remedies
Do you currently take any of the following DAILY ESSENTIAL SUPPLEMENTS?

Fish OilVitamin DGood Quality ProbioticPhytonutrient / Multi-mineral source (like a 'green' drink powder)
Please list all nutritional supplements, vitamins, herbal tinctures, homeopathic remedies you presently take and why:*

Completion !!
Is there ANYTHING ELSE we have not asked which YOU THINK WE NEED TO KNOW to better understand you, or how we might help you?*

NoOther
Please tick to acknowledge the following:*

To the best of my knowledge, my answers above are true and accurate.I consent to a professional 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
Please sign here:*

Clear
Electronically signed on this date:*

DayMonthYear
Date
Once you submit this form (click the below button) - a new page will appear with information about getting to us and preparing for your first visit.

If this is not obvious - scroll up from the bottom of our webpage and this new page will become visible!
Should be Empty:

	No	Yes
Are there any known congenital conditions/diseases of mum or dad?
Is there any known history of scoliosis
Were there any complications during pregnancy
Were there any complications during labour/birth

	No	Yes
Does your baby suffer from any neck stiffness, fever or headaches?
Have you noticed any changes in your baby's alertness (eg. drowsiness, loss of consciousness)?
Have you noticed any muscle weakness (floppiness) in your baby?

PRIVACY POLICY

HOW DID YOU FIND OUT ABOUT US?

CHOOSE THE BEST FORM FOR YOU

Extra Admin Info...

Contact Preferences

Do you have Kids?

Private Insurance

Employment or Main Life Role

Have you seen a Chiropractor before?

How can we help?

What's not working for you?

Current Life Snapshot

OUTCOMES

Details about Your Health Concerns or Challenges

Child | Teen - Specific Questions

Baby - Specific Questions

Contributors to Ill-Health

Main Health Professional

Review of Body Systems

Surgery | Medical Imaging

Medication, Supplements or Remedies

Alcohol, Tobacco & Recreational Drug use

Lifestyle & Recreation

Completion !!