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Wellness Intake Form

Wellness Intake Form Template for Malaysia

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Key Requirements PROMPT example:

Wellness Intake Form

"I need a standard Wellness Intake Form for my new wellness center in Kuala Lumpur, compliant with Malaysian regulations and suitable for general wellness services including massage therapy and nutrition counseling."

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Document background
The Wellness Intake Form is a crucial document used by wellness facilities and healthcare providers in Malaysia to gather comprehensive information about clients before providing wellness services. This form is designed to comply with Malaysian healthcare regulations, including the Personal Data Protection Act 2010, Medical Act 1971, and relevant healthcare facility regulations. It serves multiple purposes: collecting essential health information, documenting informed consent, assessing potential risks, and establishing a baseline for wellness services. The form should be completed by new clients prior to receiving any wellness services and updated periodically to ensure information accuracy. It includes sections for personal information, medical history, lifestyle assessment, and specific wellness goals, with additional optional sections for specialized services.
Suggested Sections

1. Personal Information: Client's basic details including name, IC/passport number, contact information, and emergency contact details

2. Medical History: Current and past medical conditions, surgeries, medications, and allergies

3. Lifestyle Assessment: Diet, exercise, sleep patterns, stress levels, and daily habits

4. Current Health Concerns: Primary reasons for seeking wellness services and specific health goals

5. Risk Assessment: Questions to identify potential health risks and contraindications

6. Consent and Declaration: Client's acknowledgment of information accuracy and consent for services

7. Privacy Notice: PDPA-compliant statement on how personal data will be collected, used, and protected

Optional Sections

1. Pregnancy Information: Additional section for pregnant clients, including due date, physician details, and pregnancy-specific concerns

2. Traditional Medicine History: Section for clients seeking traditional medicine services, documenting previous treatments and experiences

3. Physical Activity Readiness: Detailed questionnaire for clients interested in exercise-based wellness programs

4. Nutritional Assessment: Detailed dietary preferences, restrictions, and nutritional supplements for nutrition-focused services

5. Mental Health Screening: Optional screening for stress, anxiety, and mood-related concerns for holistic wellness assessment

Suggested Schedules

1. Schedule A - Service Terms: Detailed terms and conditions of specific wellness services offered

2. Schedule B - Fee Schedule: Breakdown of service fees and payment terms

3. Appendix 1 - Medical Clearance Form: Template for physician clearance when required

4. Appendix 2 - Body Assessment Chart: Standardized chart for recording physical measurements and assessments

5. Appendix 3 - Emergency Protocol: Detailed procedures for handling medical emergencies during sessions

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

Linkedin in social icon imageX social icon image
alex.den.21@genieai.co
Relevant Industries

Healthcare

Wellness and Fitness

Alternative Medicine

Sports and Recreation

Medical Tourism

Corporate Wellness

Spa and Beauty

Rehabilitation Services

Preventive Healthcare

Holistic Health

Relevant Teams

Operations

Clinical Services

Compliance and Legal

Customer Service

Health and Safety

Administration

Wellness Services

Quality Assurance

Client Relations

Risk Management

Relevant Roles

Wellness Coordinator

Healthcare Administrator

Wellness Practitioner

Physical Therapist

Nutritionist

Fitness Instructor

Traditional Medicine Practitioner

Medical Director

Spa Manager

Compliance Officer

Health and Safety Manager

Client Relations Manager

Wellness Program Director

Corporate Wellness Consultant

Industries
Personal Data Protection Act 2010: Regulates the collection, processing, and storage of personal data in commercial transactions, including medical information. Crucial for handling client personal information in wellness intake forms.
Medical Act 1971: Sets standards for medical practice and record-keeping in Malaysia, relevant for medical history collection and storage requirements.
Private Healthcare Facilities and Services Act 1998: Governs private healthcare facilities and services, including requirements for patient information collection and management.
Consumer Protection Act 1999: Ensures protection of consumer rights and interests, particularly relevant for wellness services and disclosure requirements.
Traditional and Complementary Medicine Act 2016: Regulates traditional and complementary medicine practices, relevant if the wellness services include alternative therapies.
Electronic Commerce Act 2006: Relevant if the intake form is digital, governing electronic transactions and records.
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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