Wellness Intake Form

Wellness Intake Form Template for United Arab Emirates

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Key Requirements PROMPT example:

"I need a comprehensive Wellness Intake Form for my Dubai-based holistic healing center opening in March 2025, which should include sections for alternative medicine treatments and accommodate both English and Arabic-speaking clients."

Document background

The Wellness Intake Form is a essential document used by wellness facilities operating in the United Arab Emirates to gather comprehensive information about new clients before providing services. This document is designed to comply with UAE Federal Law No. 2 of 2019 on healthcare ICT usage, as well as other relevant healthcare and data protection regulations. The form must be completed by all new clients and includes sections for personal information, medical history, emergency contacts, and informed consent. It serves multiple purposes: ensuring regulatory compliance, protecting both the facility and client, enabling appropriate service delivery, and maintaining accurate records as required by UAE healthcare authorities. The Wellness Intake Form is particularly crucial in the UAE's diverse healthcare landscape, where cultural sensitivity and comprehensive medical documentation are paramount.

Suggested Sections

1. Personal Information: Client's basic details including full name (as per UAE ID), Emirates ID number, date of birth, gender, and contact information

2. Emergency Contact Details: Information about primary and secondary emergency contacts including their relationship to the client

3. Medical History: Comprehensive overview of client's past and current medical conditions, surgeries, and chronic illnesses

4. Current Medications: List of all current medications, supplements, and traditional medicines being taken

5. Lifestyle Assessment: Information about daily habits, exercise routines, sleep patterns, and stress levels

6. Current Health Concerns: Description of any immediate health issues or wellness goals the client wishes to address

7. Consent and Declaration: Client's acknowledgment of information accuracy and consent for treatment, including data protection notices as per UAE law

8. Provider Information: Details of the wellness facility and primary healthcare provider as required by UAE healthcare regulations

Optional Sections

1. Dietary Information: Detailed section about dietary preferences, restrictions, and allergies - include for nutrition-focused wellness programs

2. Physical Activity History: Detailed exercise and activity history - include for fitness-related wellness programs

3. Mental Health Assessment: Questions about mental health history and current state - include for holistic wellness programs or stress management services

4. Pregnancy Information: Specific questions for pregnant clients - include if the facility offers prenatal wellness services

5. Cultural Preferences: Section addressing specific cultural considerations relevant in UAE context - include for facilities serving diverse populations

6. Insurance Information: Details of health insurance coverage - include if the facility accepts insurance payments

Suggested Schedules

1. Terms and Conditions: Detailed terms of service including cancellation policies and facility rules

2. Privacy Policy: Detailed explanation of how personal and health information will be handled in compliance with UAE data protection laws

3. Service Menu: List of available wellness services and treatments with their descriptions

4. Health Screening Questionnaire: Detailed health screening questions as required by UAE healthcare regulations

5. Liability Waiver: Specific liability limitations and client acknowledgments in accordance with UAE law

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

Wellness and Spa

Fitness and Recreation

Alternative Medicine

Physiotherapy

Mental Health and Counseling

Nutrition and Dietetics

Medical Tourism

Preventive Healthcare

Corporate Wellness

Relevant Teams

Operations

Medical Records

Patient Relations

Clinical Operations

Quality Assurance

Compliance

Front Office

Customer Service

Health Information Management

Risk Management

Relevant Roles

Wellness Center Manager

Healthcare Administrator

Medical Director

Wellness Practitioner

Physical Therapist

Nutritionist

Fitness Instructor

Spa Manager

Clinical Coordinator

Patient Relations Officer

Compliance Officer

Quality Assurance Manager

Health and Safety Officer

Medical Records Specialist

Front Desk Coordinator

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Let's create your Wellness Intake Form

Authors

Alex Denne

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