Clinical Intake Form

Clinical Intake Form Template for Netherlands

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Key Requirements PROMPT example:

"I need a Clinical Intake Form for my new dental practice opening in Amsterdam in March 2025, which should include specific sections for dental history and be available in both Dutch and English to accommodate international patients."

Document background

The Clinical Intake Form is a fundamental document used across Dutch healthcare settings to initiate the provider-patient relationship and ensure compliance with legal and medical requirements. It serves as the primary tool for collecting essential patient information at the first point of contact, incorporating elements required by the Medical Treatment Agreement Act (WGBO) and the General Data Protection Regulation (GDPR). The form is designed to gather comprehensive medical information, including patient history, current health status, and necessary consents, while ensuring that all data collection and processing meets Dutch healthcare standards. This document is particularly important as it forms the basis for the treatment agreement between healthcare providers and patients, as required by Dutch law, and ensures proper documentation of patient information and consent.

Suggested Sections

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

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

3. Current Health Concerns: Primary reason for visit and current symptoms or health issues

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

5. Current Medications: List of current medications, dosages, and supplements

6. Allergies and Reactions: Known allergies to medications, substances, or materials and type of reactions

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

8. Lifestyle Information: Smoking, alcohol use, exercise habits, and other lifestyle factors

9. Privacy Statement: GDPR-compliant privacy notice explaining how personal data will be processed

10. Consent Declaration: Patient's consent for treatment and data processing as per WGBO requirements

Optional Sections

1. Mental Health History: Optional section for mental health conditions and treatments, used when mental health services may be relevant

2. Occupational Health Information: Details about work-related health risks and concerns, included when occupational health is relevant

3. Pregnancy and Gynecological History: For female patients when relevant to current care

4. Cultural/Religious Considerations: Special cultural or religious considerations that may affect treatment, included when relevant to patient care

5. Language and Communication Preferences: For patients who may require interpretation services or have specific communication needs

6. Social Support Assessment: Information about living situation and support systems, included for elderly or vulnerable patients

Suggested Schedules

1. Medication List Template: Detailed template for listing current medications with dosage schedules

2. Privacy Notice: Detailed GDPR-compliant privacy notice explaining data processing practices

3. Patient Rights Document: Summary of patient rights under Dutch healthcare laws

4. Consent Forms: Specific consent forms for various treatments or data processing activities

5. Medical History Questionnaire: Detailed questionnaire for systematic collection of medical history

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

Medical Services

Mental Health

Primary Care

Specialist Care

Dental Care

Physical Therapy

Occupational Health

Alternative Medicine

Rehabilitation Services

Relevant Teams

Administration

Medical Records

Compliance

Legal

Patient Services

Quality Assurance

Data Protection

Clinical Operations

Front Desk

Information Management

Relevant Roles

Healthcare Administrator

Medical Doctor

Nurse Practitioner

Clinical Coordinator

Practice Manager

Medical Records Officer

Privacy Officer

Healthcare Compliance Officer

Quality Assurance Manager

Patient Services Coordinator

Clinical Director

Medical Secretary

Healthcare Legal Counsel

Data Protection Officer

Patient Registration Specialist

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