Health Intake Form Template for Netherlands

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Key Requirements PROMPT example:

Health Intake Form

"I need a comprehensive Health Intake Form for my new physiotherapy practice opening in Amsterdam in March 2025, with special focus on sports injuries and including sections for exercise history and physical activity levels."

Document background

The Health Intake Form is a fundamental document used across Dutch healthcare settings to establish the initial patient-provider relationship and collect essential health information. This document is typically completed by new patients before their first consultation or when registering with a new healthcare provider. The form includes sections for personal information, medical history, current health status, and necessary GDPR-compliant consent declarations. It must comply with Dutch healthcare legislation, including the Medical Treatment Agreement Act (WGBO), GDPR, and specific Dutch healthcare privacy regulations. The information collected through this form serves as the foundation for creating patient records and ensuring appropriate medical care while maintaining patient privacy and data protection standards.

Suggested Sections

1. Personal Information: Basic identification details including name, date of birth, BSN number, contact information, and emergency contact details

2. Insurance Information: Health insurance provider details, policy number, and coverage information

3. Medical History: Overview of past medical conditions, surgeries, hospitalizations, and chronic conditions

4. Current Health Status: Present health concerns, symptoms, and ongoing treatments

5. Medications: Current medications, dosages, supplements, and known drug allergies

6. Family Medical History: Relevant family health conditions and genetic predispositions

7. Lifestyle Information: Information about diet, exercise, smoking, alcohol consumption, and other lifestyle factors

8. Data Processing Consent: GDPR-compliant consent section for processing health data and sharing with relevant healthcare providers

9. Declaration: Patient declaration confirming information accuracy and understanding of data usage

Optional Sections

1. Mental Health History: Optional section for mental health conditions and treatments, used when the practice includes mental health services

2. Pregnancy History: For practices dealing with women's health or when relevant to current treatment

3. Occupational Health: Details about work-related health risks and concerns, used when occupational health is relevant

4. Sports and Physical Activity: Detailed section about sports participation and exercise routines, relevant for sports medicine or physiotherapy practices

5. Cultural/Religious Considerations: Special healthcare considerations related to cultural or religious beliefs, included when relevant to the healthcare setting

6. Alternative Medicine History: Information about alternative treatments and therapies, used in integrative medicine practices

Suggested Schedules

1. Privacy Notice: Detailed information about how personal data is collected, processed, stored, and shared

2. Medical Conditions Checklist: Comprehensive checklist of common medical conditions for patient reference

3. Medication List Template: Structured template for listing current medications and dosages

4. Patient Rights Information: Document outlining patient rights under Dutch healthcare law

5. Practice Information: Details about the healthcare practice, including contact information, emergency procedures, and complaint procedures

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

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Mental Healthcare

Primary Care

Specialist Medical Care

Allied Health Services

Preventive Healthcare

Occupational Health

Sports Medicine

Alternative Medicine

Relevant Teams

Reception

Administration

Medical Records

Compliance

Data Protection

Quality Assurance

Patient Services

Clinical Operations

Legal

Information Technology

Relevant Roles

General Practitioner

Medical Specialist

Practice Manager

Healthcare Administrator

Medical Records Officer

Privacy Officer

Compliance Manager

Healthcare Quality Manager

Nurse Practitioner

Physician Assistant

Medical Secretary

Healthcare Receptionist

Data Protection Officer

Clinical Director

Patient Services Coordinator

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Authors

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