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Wellness Intake Form

Wellness Intake Form Template for Nigeria

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Key Requirements PROMPT example:

Wellness Intake Form

"I need a simple Wellness Intake Form for my small traditional medicine practice in Lagos, Nigeria, focusing on collecting essential health information and incorporating sections for traditional medicine history, with implementation planned for January 2025."

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Document background
The Wellness Intake Form serves as a crucial document for healthcare providers in Nigeria to gather comprehensive information about new clients seeking wellness services. This form is designed to comply with Nigerian healthcare regulations, including the NDPR 2019 and National Health Act 2014, while collecting essential data about a client's health status, medical history, and current wellness needs. The document should be completed prior to the initial consultation and includes sections for personal information, medical history, current medications, lifestyle factors, and emergency contacts. Healthcare providers use this information to develop appropriate wellness plans, ensure safe service delivery, and maintain accurate records as required by Nigerian law. The form is particularly important in establishing the baseline health status of clients and identifying any potential contraindications for proposed wellness treatments or services.
Suggested Sections

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

2. Medical History: Current and past medical conditions, surgeries, hospitalizations, and chronic conditions

3. Current Medications: List of all current medications, supplements, and herbs, including dosages and frequency

4. Family Health History: Relevant family medical history focusing on hereditary conditions

5. Lifestyle Information: Diet, exercise habits, sleep patterns, stress levels, and occupation-related health factors

6. Current Symptoms: Present health concerns and symptoms that prompted seeking wellness services

7. Privacy Notice and Consent: NDPR-compliant privacy statement and consent for data collection and processing

8. Declaration and Signature: Client's confirmation of accurate information provision and acknowledgment of terms

Optional Sections

1. Insurance Information: Details of health insurance if applicable for wellness services coverage

2. Traditional Medicine History: Section for recording use of traditional Nigerian medical treatments and herbs

3. Spiritual/Religious Considerations: Religious or spiritual practices that may impact treatment preferences

4. Preferred Language: Language preferences for multicultural clients, particularly relevant in diverse Nigerian communities

5. Dietary Restrictions: Detailed section for cultural, religious, or health-based dietary restrictions

Suggested Schedules

1. Medical Conditions Checklist: Comprehensive checklist of common medical conditions for client reference

2. Medication List Template: Structured template for detailed medication information

3. Lifestyle Assessment Questionnaire: Detailed questionnaire about daily habits and lifestyle factors

4. Privacy Policy: Detailed NDPR-compliant privacy policy and data protection information

5. Symptom Diary Template: Optional template for tracking symptoms and wellness progress

Authors

Alex Denne

Head of Growth (Open Source Law) @ ¶¶Òõ¶ÌÊÓƵ | 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 Fitness

Alternative Medicine

Medical Tourism

Corporate Wellness

Sports Medicine

Preventive Healthcare

Holistic Health

Traditional Medicine

Insurance

Relevant Teams

Reception

Medical Records

Clinical Operations

Compliance

Patient Services

Quality Assurance

Wellness Services

Administrative Services

Legal

Data Protection

Relevant Roles

Wellness Coordinator

Healthcare Administrator

Medical Doctor

Nurse Practitioner

Physiotherapist

Nutritionist

Wellness Coach

Alternative Medicine Practitioner

Fitness Instructor

Medical Records Officer

Compliance Officer

Privacy Officer

Clinical Director

Patient Services Manager

Traditional Medicine Practitioner

Industries






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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