• ADULT MEMBER INTAKE

    CONFIDENTIAL details about current/past health, stress-load & the outcomes you want.

  • Welcome to Optimal Life Health Centres in Noosa

    Please complete this form with 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 the 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 Did You Find Our Health Centre' below). Next and Back buttons will appear once each page is complete.

    • How Did You Find Our Health Centre?  

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


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    • 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?

    • 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 the loved ones, friends and colleagues YOU refer to us and we are deeply grateful for your introductions. 
      The potential benefits of chiropractic care when combined with health and wellness coaching are many, and different people may experience different results. We offer SO much more than help for sore necks and backs!

  • Personal Information

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

  • OPTIONAL: Provide us with a photo so we recognise you when you arrive!
    A) Take a photo below if your device has an inbuilt camera, or B) upload one if you prefer!

    • A) Name, address etc.  

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

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    • B) How Do We Contact You?  

    • Contact Phone Numbers:
      Please provide a primary number and a backup if possible. At least one number is required.

      If you DON'T have a mobile, enter your landline number in the "Mobile" box instead of the Home box. 

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

    • We use your preferred means of contact whenever possible, yet we may use any of the above methods and/or post. 
      If you DO NOT want contact by any particular method please tell us.

      We send email relevant to your chiropractic care...however we don't want to 'spam' you!
      Please tell us if our email content or frequency is unwelcome. 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)

    • C) Basic Details about Insurance | Family | Work  

    • Details about Private Insurance...

    • 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.

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

      Having some basic details about your relationship and/or family helps us assess some potential stressors that may be impacting your life and how effectively you may heal.
      Plus...we like to be able to say "Hi!" if your family visit with you!

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

      Knowing some detail about your work or daily activity can help us assess some potential stresses that may be impacting your life and how effectively you may heal. In fact, this may be a primary source of stress and may play a large role in what types of outcomes you can expect.

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    • Thanks, that's this section complete! Click NEXT (below)...

  • How can we help?

    (and your past experience 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. Your comfort and confidence in who we are and what we do is important!

  • Your experience or history with Chiropractic care...


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  • "Wellness" chiropractors help you GET well and also STAY well.
    They recommend ongoing, regular care looking for underlying causes of ill-health and helping you learn & implement healthier behaviours to live a more vibrant, extraordinary life

    "Pain & Condition" chiropractors primarily (perhaps exclusively) focus on getting you out of pain.
    They usually choose to deal just with your current acute problem/s - usually seeing you short-term only to help you 'fix' a 'problem'

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

  • If they will do this by identifying you over the phone, have them send records to: healthier@optimallife.net.au

    If they request a Records Release Authority form: download this form here.
    Complete it and then scan & e-mail or fax it to them.

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    • How Can We Help You?  

    • Some people seek our help when they are experiencing health challenges: symptoms, concerns, complaints, discomfort or dysfunction. We definitely people in these situations!

      Our focus though, is preventative, proactive healthcare! Many of our centre-members see us regularly to improve how they function. 
      What do they get from this?       Enhanced health and wellbeing & help toward living a more vibrant, extraordinary life...we welcome you to learn about this and 'give it a go'

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

    • Health Challenges or Concerns:  

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

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

    • 0 = No Pain / 10 Worst imaginable

    • 0 = No Pain / 10 Worst imaginable

    • 0 = No Pain / 10 Worst imaginable

    • 0 = No Pain / 10 Worst imaginable

    • 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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    • What things make your situation worse or better?  
    • What IMPACT is this having on your life?  



    • 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?  

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

  • Stress Survey & Health Self-ratings!

    • The most important part of this form!  

    • Stress is not just "worry." Stress (or an individual stressor) is neither good nor bad - problems occur only if your nervous system can't adapt to or dissipate the stress effectively...which leads to build-up, and then breakdown, of body control systems (this is what disease is!).

      Potential stressors can be broadly categorised as either Physical, Chemical or Mental-Emotional. Stressors can cause or contribute to an identical response in your body in combination or by themselves. They may affect how we function, whether we have health 'problems' and even how well we heal.

      This is section is critically important!

      For each of the three categories below, select any options that have affected or do currently affect you 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 affecting you and your function).

    • Health Self-Ratings  

    • Please RATE yourself on the following areas so we get a picture of how healthy you think you are...

    • If   0 = DEAD   and   100 = Your Best Possible Life
      (where life is vibrant, healthy, fun, happy, creative, passionate, fulfilled...)

      how would you rate the overall quality of your health and life right now? 

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

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

  • General Medical History & Systems Review

    • "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. 

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


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

    • Medical History  

    • Major Illnesses or Diagnoses:

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

    • Surgery or Hospital Stays:

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


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    • Over-the-Counter or Prescribed Medication Use:

    • A little more Biochemistry!  

    • Supplements & Vitamins:

    • Alcohol & Tobacco Use:

    • 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.


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    • 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 different "health" approaches exist. Both are IMPORTANT & VALUABLE in different circumstances.

    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".


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    • Proactive Health Team:  

    • Seeing health providers consistently can help you achieve true HEALTH-care.
      Such providers often suggest you see them whether or not you have symptoms, to identify potential problems before they become a crisis, to give ADVICE and help IMPROVE on how you look after yourself.

    • Dental Health / Hygiene:  

    • 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!

    • What do you do for recreation...  
    • Empowering Activities...  
    • Your Birth:  

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


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    • Walking / Your Feet  

    • 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?

  • One final question...


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