Intake Assessment Form

Intake Assessment Form Template for United Arab Emirates

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Key Requirements PROMPT example:

"I need an Intake Assessment Form for my new private dental clinic opening in Dubai Healthcare City in January 2025, which must include specialized dental history sections and be compliant with both DHCC and UAE federal healthcare regulations."

Document background

The Intake Assessment Form is a crucial document used across healthcare facilities in the United Arab Emirates for gathering comprehensive information about new patients or clients. This standardized form ensures compliance with UAE healthcare regulations, including Federal Law No. 2 of 2019 on health data protection and Federal Law No. 5 of 2019 on healthcare practice. The form collects essential information including personal details, medical history, insurance information, and necessary consents, while adhering to UAE data protection requirements. It serves as the foundation for creating patient records and developing treatment plans, making it essential for healthcare providers operating in the Emirates. The document is designed to be adaptable for various healthcare settings while maintaining consistency with UAE healthcare documentation standards.

Suggested Sections

1. Personal Information: Basic identification details including name, Emirates ID, date of birth, gender, nationality, and contact information

2. Emergency Contact Details: Information about primary and secondary emergency contacts

3. Insurance Information: Health insurance details including policy number, provider, and coverage type

4. Medical History: Current medications, allergies, chronic conditions, and previous medical procedures

5. Current Symptoms/Concerns: Primary reason for visit and description of current issues

6. Lifestyle Information: Basic lifestyle factors including smoking status, exercise habits, and dietary preferences

7. Family Medical History: Relevant family medical conditions and genetic predispositions

8. Consent and Declaration: Patient consent for treatment and information sharing, compliant with UAE healthcare laws

9. Privacy Notice: Information about data collection and processing in accordance with UAE data protection laws

Optional Sections

1. Mental Health Assessment: Used for psychological or psychiatric intake - includes mental health history and current psychological state

2. Substance Use History: Required for addiction treatment services - details current and past substance use

3. Pediatric Information: Additional section for patients under 18 - includes developmental history and vaccination records

4. Pregnancy History: For obstetric/gynecological services - includes pregnancy and reproductive health information

5. Disability Assessment: For patients requiring accessibility accommodations or special assistance

6. Cultural/Religious Preferences: Optional section for noting specific cultural or religious requirements affecting care

7. Language and Communication: For non-Arabic/non-English speakers - details preferred language and interpreter needs

Suggested Schedules

1. Medical Records Release Authorization: Standard form for authorizing release of medical records from previous healthcare providers

2. Insurance Documentation: Copies of insurance cards and coverage verification forms

3. Identification Documents: Copies of Emirates ID, passport, and other relevant identification

4. Pain Assessment Charts: Standard pain location and intensity assessment diagrams

5. Medication List Template: Detailed template for current medication documentation

6. Health Screening Questionnaire: Standardized health screening questions as per UAE healthcare requirements

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 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

Mental Health Services

Social Services

Rehabilitation Services

Insurance

Medical Education

Pharmaceutical

Healthcare Technology

Wellness and Prevention

Elder Care

Pediatric Care

Relevant Teams

Administration

Clinical Operations

Patient Services

Medical Records

Compliance

Quality Assurance

Insurance Coordination

Front Desk

Data Management

Legal and Regulatory

Relevant Roles

Medical Director

Healthcare Administrator

Physician

Nurse Practitioner

Registered Nurse

Medical Records Manager

Clinic Manager

Patient Services Coordinator

Healthcare Compliance Officer

Quality Assurance Manager

Insurance Coordinator

Clinical Director

Practice Manager

Intake Coordinator

Healthcare Data Manager

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Authors

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