Application – Building Wellness Application - BUILDING WELLNESS PROGRAM Step 1 of 8 12% Please complete the following application for the Building Wellness program with Influence Medical. This application is used to gather data about our prospective participants and for us to determine if your participation is an appropriate action for you. When completing the application please note that some fields* are required, but most are optional as you may wish to be selective about what you disclose. This information is used for assessment and administrative purposes only and will be kept confidential and private. Your contact information will be used for internal use only. Navigation through the application is simple; you can use the PREV or NEXT button to move through the pages. When complete, click the SUBMIT button. This action submits the data to us electronically. You will be asked to make standard agreements regarding copyright, confidentiality and participation as a requirement of your participation. If you have any additional questions, please contact Dr Gary Ward at admin@influencemedical.com.au.Personal DetailsFirst Name*Last Name*Date of Birth* Date Format: DD slash MM slash YYYY Address* City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Contact DetailsBest way to reach me:* Email Mobile Home Phone Work Phone Skype Email Address* MobileHome PhoneWork PhoneSkype Username General InformationRelationship StatusSingleEngagedMarriedIt's complicatedIn a relationshipWidowedSeparatedDivorcedIn a civil unionIn a domestic partnershipHighest Education Level AchievedDid Not Complete High SchoolHigh SchoolUniversityBachelor's DegreeMaster's DegreeAdvanced Graduate work or Ph.D. Company Details (if applicable)Company NamePosition/TitleCompany Website Address Medical DetailsYour Usual General Practitioner*Other Regular Medical AdvisorsWhen was your last comprehensive medical examination? At Influence Medical we focus on your Wellbeing. We define Wellbeing as "a good or satisfactory condition of existence"; or "a state characterized by a good or satisfactory condition of physical health, emotional health or happiness, and financial security or prosperity". Please use the following to rate your current level of Wellbeing.How would you assess your current state of physical health?*ExcellentGoodAverageFairPoorThis rating might include presence or absence of illness or symptoms, your physical fitness or a general sense of your overall physical health.Comment:How would you assess your current state of emotional health or happiness?*ExcellentGoodAverageFairPoorComment:How would you assess your current state of financial security or prosperity?*ExcellentGoodAverageFairPoorComment:Do you have specific health and wellbeing goals? If so, what are they?What concerns or obstacles do you face in achieving your health and wellness goals?With respect to your health and wellbeing, would you describe yourself as ? (Choose one or more) Despondent Resigned Naïve Satisfied Curious Responsible Actively engaged Ambitious Highly motivated Application CompletionPlease check all to confirm your understanding of the BUILDING WELLNESS Program* I understand my membership is for 12 months with an opportunity to review annually I understand that there are fees for the service including a non-refundable deposit or registration fee. I understand that the program may be rigorous and challenging and I am counting on that to support me. I understand that I may withdraw from the program or service (or be withdrawn) and will receive a proportional refund. I understand and accept the standard copyright, confidentiality, privacy and participation Terms of Use and Agreements* * Terms of Use and Program Agreements The following outlines the conditions and requests that are a requirement of your participation in the services or programs of Influence Medical. If you have any questions about these conditions and requests, please contact us at admin@influencemedical.com.au Please note that your understanding and acceptance of these conditions is a requirement of your participation. Copyright: The material presented in this program or service is an original creation of Dr Gary Ward and Influence Medical and is copyrighted and protected under the applicable laws. We ask that you not duplicate or distribute any of the materials in any form. We ask that you not use or repurpose this material without the express written consent of Dr Gary Ward or an authorised representative of Influence Medical. Participation: Your participation in this service or program must be voluntary and without coercion. We request that you participate to the best of your ability and inform the service provider or program leader if you have any concerns or questions about the material presented. Privacy: Your personal information will be collected and retained in compliance with the Privacy Act (1988). The purpose of collecting your personal information is to provide quality medical and health related services and associated account keeping. We ask that you consent to Dr Gary Ward (or an authorized representative of Influence Medical) collecting, using, storing and disposing of your personal information, and to releasing relevant information to other Health Professionals to enhance your participation in the program. Disclaimer: We make no promise that participation in this program will guarantee that you will not become ill, develop a debilitating condition, or die. Your understanding and acceptance of this disclaimer is a requirement of your participation. Confidentiality: In any of the public sessions (Group or Virtual Seminars), personal information that may be of a sensitive nature may be shared. We insist that you keep confidential any information you hear on these sessions. Please note that although we demand confidentiality, we cannot guarantee it. Therefore, please be responsible for your sharing. Participation: We request you participate in public sessions (Group or Virtual Seminars) only to the extent that you feel comfortable. Coaching: We request that you do not offer coaching or advice to other participants or the program leaders unless requested specifically to do so.* I accept When you are complete with your application, press the SUBMIT button. Thank you.
