Wellness Intake Form Template for England and Wales

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Key Requirements PROMPT example:

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."

Document background
The Wellness Intake Form is a crucial document used across various wellness and healthcare settings in England and Wales. It serves as the initial point of contact between service providers and clients, collecting vital information necessary for safe and effective service delivery. The form is designed to comply with UK GDPR and healthcare regulations while gathering comprehensive data about a client's health status, medical history, and lifestyle factors. This intake form helps practitioners assess client needs, identify potential contraindications, and maintain accurate records for both medical and legal purposes. It typically includes both mandatory and optional sections depending on the specific services being offered.
Suggested Sections

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

Optional Sections

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

Suggested Schedules

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

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Relevant Industries
Relevant Teams
Relevant Roles
Industries

UK GDPR and Data Protection Act 2018: Core legislation governing the collection, processing, storage and protection of personal and sensitive health data. Essential for handling client information in wellness intake forms.

Consumer Rights Act 2015: Ensures fairness in contract terms and service provisions. Relevant for protecting client interests and establishing clear service terms in wellness agreements.

Health and Safety at Work Act 1974: Applicable when the wellness intake form is used in a professional setting, ensuring proper health and safety protocols are followed.

Access to Health Records Act 1990: Governs the handling and accessibility of medical history and health information collected through the intake form.

Mental Capacity Act 2005: Provides framework for making decisions for those who lack capacity to do so themselves. Important when dealing with vulnerable adults or those with diminished capacity.

Equality Act 2010: Ensures non-discrimination in service provision and requires consideration of reasonable adjustments for clients with protected characteristics.

Professional Standards Regulations: Includes requirements from relevant regulatory bodies and industry-specific standards that must be adhered to in wellness practice.

Common Law Duty of Confidentiality: Legal obligation to protect client confidentiality and maintain professional-client privilege in all communications and record-keeping.

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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