Holistic Intake Form

Holistic Intake Form Template for Netherlands

A comprehensive intake form designed for use in Dutch healthcare and wellness settings, compliant with Netherlands healthcare regulations including WGBO and AVG (GDPR). This document serves as the initial assessment tool for gathering detailed patient information across multiple health dimensions, including physical, mental, and emotional well-being. It incorporates mandatory privacy notices, informed consent requirements, and detailed health history documentation, while adhering to Dutch healthcare documentation standards and patient rights legislation.

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What is a Holistic Intake Form?

The Holistic Intake Form serves as an essential first point of contact between healthcare providers and patients in the Netherlands, designed to gather comprehensive information about a patient's health status, medical history, and wellness goals. This document is typically used at the initial consultation in various healthcare settings, from complementary medicine practices to integrated health clinics. It complies with Dutch healthcare regulations, including the Medical Treatment Contracts Act (WGBO), the General Data Protection Regulation (AVG/GDPR), and the Healthcare Quality, Complaints and Disputes Act (Wkkgz). The form includes sections for personal information, medical history, lifestyle factors, and consent declarations, ensuring both legal compliance and thorough patient assessment. It serves as a foundation for creating personalized treatment plans while maintaining proper medical documentation as required by Dutch law.

What sections should be included in a Holistic Intake Form?

1. Personal Information: Basic client details including name, date of birth, contact information, emergency contacts, and preferred language

2. Privacy Notice and Consent: GDPR-compliant privacy statement and consent for data processing, including specific consent for sharing information with other healthcare providers if necessary

3. Current Health Concerns: Primary reasons for seeking treatment, current symptoms, and health goals

4. Medical History: Past illnesses, surgeries, hospitalizations, accidents, and chronic conditions

5. Medication and Supplements: Current medications, supplements, herbs, and any known drug allergies or reactions

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

7. Lifestyle Assessment: Diet, exercise, sleep patterns, stress levels, occupation, and daily routines

8. Mental and Emotional Health: Current mental health status, stress levels, emotional well-being, and relevant history

9. Healthcare Provider Information: Details of other healthcare providers involved in the client's care

10. Declaration and Signature: Client's confirmation that provided information is accurate and consent for treatment

What sections are optional to include in a Holistic Intake Form?

1. Pregnancy and Fertility: Section for individuals who are pregnant, trying to conceive, or have reproductive health concerns

2. Pain Assessment: Detailed pain evaluation section for clients with chronic pain or specific pain conditions

3. Traditional Medicine Use: Section for recording use of traditional medicines or cultural healing practices

4. Sports and Physical Activity: Detailed section for active individuals or athletes regarding training and performance

5. Environmental Factors: Section addressing environmental exposures, sensitivities, and living conditions

6. Dietary Restrictions: Detailed section for those with specific dietary requirements or restrictions

7. Insurance Information: Section for recording health insurance details if applicable to the treatment

What schedules should be included in a Holistic Intake Form?

1. Pain Diagram: Body diagram for marking areas of pain or discomfort

2. Medication List Template: Detailed template for listing all current medications and supplements

3. Food Diary Template: Template for recording dietary intake

4. Symptom Tracking Sheet: Template for monitoring symptoms over time

5. Privacy Policy: Detailed GDPR-compliant privacy policy

6. Treatment Consent Form: Detailed informed consent document for specific treatments

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents

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Download a Standard Holistic Intake Form

Review your own Holistic Intake Form

What is a Holistic Intake Form?

What sections should be included in a Holistic Intake Form?

What sections are optional to include in a Holistic Intake Form?

What schedules should be included in a Holistic Intake Form?

Authors

Alex Denne

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