{"content":{"sections":[{"name":"General Information","questions":[{"name":"First & Last Name","type":"text","required":true},{"name":"Date of Birth","type":"text","required":true},{"name":"Home Phone Number","type":"text"},{"name":"Mobile Phone Number","type":"text"},{"name":"Email Address","type":"text"},{"name":"Home Address","type":"paragraph","required":true}]},{"name":"General Questions","questions":[{"name":"Occupation","type":"text"},{"name":"Do you have any children?","type":"radiobuttons","answers":[{"value":"Yes"},{"value":"No"}]},{"name":"If yes, how many and what year/s were they born?","type":"text"},{"name":"General Practitioner (please include the name of the medical centre and or your GP)","type":"text"},{"name":"Do you have health care insurance?","type":"radiobuttons","answers":[{"value":"Southern Cross"},{"value":"NIB"},{"value":"Other"},{"value":"No health care insurance"}]}],"description":"<div>We just need to know a few more things about you.</div>"},{"name":"Chiropractic History","questions":[{"name":"Chiropractor (please include the chiropractor's name and or clinic name)","type":"text"},{"name":"When did you last see a chiropractor and for what reason?","type":"paragraph"}],"description":"<div>Please fill in this section if you have seen a chiropractor in the past, if not please skip to the next section. </div>"},{"name":"Current Health","questions":[{"name":"What is the main reason for coming to see us?","type":"radiobuttons","answers":[{"value":"Primary Health Concern"},{"value":"Wellness/Health Check"}],"required":true},{"name":"If you have selected Wellness/Health check, please describe your health goals.","type":"paragraph"}]},{"name":"Primary Health Concern","questions":[{"name":"What is/are your main concerns?","type":"paragraph"},{"name":"When and how did it/they start?","type":"paragraph"},{"name":"Did you have any of the following - prior to or during the onset? (Illness/Infection, Trauma/Accident, Period of high stress, other significant event - please provide details if so)","type":"paragraph"},{"name":"Does anything relieve your symptoms?","type":"paragraph"},{"name":"Does anything make your symptoms worse? (please include if you feel worse at any specific time of the day/night)","type":"paragraph"},{"name":"Do any of the following sensations apply? (dull, burning, aching, throbbing, deep, sharp, shooting, nagging, numbness, tingling, weakness, weird - if so please provide details including the location of the sensations)","type":"paragraph"},{"name":"Do any of the sensations above, radiate up/down any of your arms or legs? (if yes, please provide details)","type":"paragraph"},{"name":"Have you had any other treatment for your major health concern/s? (if yes, please describe the treatment you have received including the name of the health care provider if possible)","type":"paragraph"}],"description":"<div>Please complete this section if you selected 'Primary Health Concern' above. Otherwise, please skip to the next section. </div>"},{"name":"General Health Information","questions":[{"name":"Are you currently taking any medications or supplements? (if yes, please list these and the reason you are taking each one).","type":"paragraph"},{"name":"Any diseases, accidents or surgery? (if yes, please provide further details)","type":"paragraph"},{"name":"Musculoskeletal - have you experienced any of the following recently?","type":"checkboxes","answers":[{"value":"Neck pain/stiffness"},{"value":"Shoulder/hands or arms pain"},{"value":"Numbness in the arms/hands"},{"value":"Low back pain"},{"value":"Legs or feet pain"},{"value":"Numbness in the legs or feet"},{"value":"Joint swelling"}]},{"name":"Neurological - have you experienced any of the following recently?","type":"checkboxes","answers":[{"value":"Headaches"},{"value":"Dizziness"},{"value":"Loss of balance"},{"value":"Loss of memory"},{"value":"Loss of smell or taste"},{"value":"Muscle weakness"},{"value":"Blackouts/Fainting"}]},{"name":"Cardiovascular - have you experienced any of the following recently?","type":"checkboxes","answers":[{"value":"High blood pressure"},{"value":"Stroke/Heart attack"},{"value":"Chest pains"},{"value":"Chronic cough"},{"value":"Asthma"}]},{"name":"Abdominal - have you experienced any of the following recently?","type":"checkboxes","answers":[{"value":"Tummy upset/pain"},{"value":"Diarrhoea/Constipation"},{"value":"Blood in urine or faeces"},{"value":"Hemorrhoids (piles)"},{"value":"Sexual dysfunction"}]},{"name":"General -  have you experienced any of the following recently?","type":"checkboxes","answers":[{"value":"Sleeping problems"},{"value":"Fever"},{"value":"Sinus"},{"value":"Allergies"},{"value":"Frequent colds"},{"value":"Fatigue"},{"value":"Depression"},{"value":"Irritability"},{"value":"Nervousness/Anxiety"},{"value":"Lights bother eyes"},{"value":"Diabetes"},{"value":"Shortness of breath"},{"value":"Unexplained weight loss"},{"value":"Cancer"}]},{"name":"Women's Health -  have you experienced any of the following recently?","type":"checkboxes","answers":[{"value":"Irregular cycle"},{"value":"Breast lumps"},{"value":"Painful menstruation"},{"value":"Pregnancy"},{"value":"Pre/Post Menopause"}]},{"name":"Is there anything else you would like the Chiropractor to know?","type":"paragraph"}],"description":"<div>In order to provide you with the best possible care, we need to know some information about your general health and well-being. </div>"},{"name":"Lifestyle","questions":[{"name":"How would you rate your overall sense of well-being?","type":"text"},{"name":"How would you rate your current stress levels?","type":"text"},{"name":"How good is your diet/nutrition?","type":"text"},{"name":"Do you drink alcohol?","type":"text"},{"name":"Do you currently smoke? (if yes - how frequently?, if no - have you ever smoked/when was your last cigarette?)","type":"text"}],"description":"<div>Please tell us some information about your lifestyle. </div>"},{"name":"Family History","questions":[{"name":"Father's Side","type":"checkboxes","answers":[{"value":"Heart disease"},{"value":"Arthritis"},{"value":"Cancer"},{"value":"Diabetes"}]},{"name":"Mother's Side","type":"checkboxes","answers":[{"value":"Heart disease"},{"value":"Arthritis"},{"value":"Cancer"},{"value":"Diabetes"}]}],"description":"<div>Please let us know if there is medical history of any of the below in your immediate family, including your grandparents. </div>"},{"name":"Consent - Chiropractic Care","questions":[{"name":"I consent to receiving care as recommended by my Chiropractor.","type":"radiobuttons","answers":[{"value":"Yes"},{"value":"No"}],"required":true}],"description":"<div>Chiropractic involves specifically targeted adjustments of the spine to safely restore normal function. This includes unlocking the joints of the spine that may not be moving as they should. You may hear a popping sound during your adjustments which is the natural noise of the gas being released from a joint being unlocked. You may occasionally feel some muscular discomfort or lightheadedness following your first adjustments. These symptoms occur as a result of change to the nervous system and your body adapting to those changes. </div>"},{"name":"Consent - Clinical Information","questions":[{"name":"I give consent for my clinical information to be shared with my general practitioner and or another registered health provider where appropriate.","type":"radiobuttons","answers":[{"value":"Yes"},{"value":"No"}],"required":true},{"name":"I give consent for Two Hands Health Ltd to request my clinical information, previous notes and X-rays from my previous Chiropractor or other health care provider where appropriate.","type":"radiobuttons","answers":[{"value":"Yes"},{"value":"No"}],"required":true}],"description":"<div>As you may have been referred to us by your medical practitioner or other health care provider, it is standard practice to request your previous notes and X-rays where appropriate from your health care providers. It is also standard practice for us to share your clinical information with your general practitioner and or another registered health provider where appropriate. </div>"},{"name":"Consent - Digital Data Storage","questions":[{"name":"I give consent for Two Hands Health LTD to store and manage my clinical and personal information digitally.","type":"radiobuttons","answers":[{"value":"Yes"},{"value":"No"}],"required":true}],"description":"<div>Two Hands Health LTD is a modern health practice and as such we use digital technology for the storage and management of patient data including but not limited to; contact information and clinical records. We use Cliniko, (www.cliniko.com) an online Patient Management System to store and manage your data. We also use email services from Google Inc to communicate with you, as such your contact data (name, email address) shared on this form is stored in the Google Inc GSuite services. Please see our privacy policy for further information. </div>"},{"name":"Signature","questions":[{"name":"Signature","type":"signature","required":true}],"description":"<div>Please sign below to confirm your consent as indicated in your selections above (use finger or mouse).</div>"},{"name":"Thank you!","questions":[{"name":"How did you hear about Two Hands Health?","type":"checkboxes","answers":[{"value":"Friend/Family"},{"value":"Facebook/Social Media"},{"value":"Health Care Professional"},{"value":"Newspaper/Newsletter"},{"value":"Leaflet/Business Card from a local business"},{"value":"Google"},{"value":"Other"}]}]}]},"name":"New Patient Form","restricted_to_practitioner":false}