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Wellness Intake Form
"I need a Wellness Intake Form for my new holistic health clinic opening in March 2025, focusing on collecting detailed medical history and lifestyle information while ensuring compliance with UK GDPR requirements for a small practice with fewer than 50 clients."
1. Personal Information: Basic contact details, emergency contacts, date of birth, and identification information
2. Medical History: Current and past health conditions, medications, allergies, surgeries, and treatments
3. Lifestyle Information: Exercise habits, diet, sleep patterns, stress levels, occupation, and daily activities
4. Privacy Notice: GDPR-compliant information about how personal data will be collected, processed, stored and protected
5. Consent Declaration: Client's explicit agreement to information sharing, treatment, and acknowledgment of privacy terms
1. Family Medical History: Optional section for collecting information about genetic conditions and family health patterns when relevant to treatment
2. Mental Health Assessment: Optional section for evaluating mental health status, stress levels, and emotional well-being when offering related services
3. Dietary Preferences: Optional section for detailed nutritional information and dietary restrictions when nutrition services are included
4. Physical Activity Readiness: Optional section for assessing fitness levels and exercise capability when physical activities are part of the wellness program
1. Terms and Conditions: Detailed service terms, cancellation policies, liability provisions, and legal disclaimers
2. Privacy Policy: Comprehensive data protection procedures, confidentiality measures, and information handling protocols
3. Medical Release Authorization: Standard form for authorizing the release of medical records from other healthcare providers if needed
Authors
Personal Information
Medical History
Health Data
Service Provider
Client
Confidential Information
Emergency Contact
Treatment
Pre-existing Conditions
Consent
Privacy Notice
Data Protection Legislation
Medical Professional
Health Assessment
Lifestyle Information
Contraindications
Treatment Plan
Healthcare Provider
Medical Release
Sensitive Personal Data
Terms and Conditions
Professional Services
Records
Authorized Representative
Emergency Contact Information
Medical History
Current Health Status
Lifestyle Assessment
Consent
Confidentiality
Data Protection
Privacy Notice
Information Sharing
Medical Release
Health and Safety
Liability
Insurance
Record Keeping
Disclosure
Terms of Service
Cancellation Policy
Client Rights and Responsibilities
Professional Disclaimer
Communication Preferences
Documentation Storage
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