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Health Intake Form Template for New Zealand

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Key Requirements PROMPT example:

Health Intake Form

"I need a Health Intake Form for my new medical practice opening in March 2025, which includes both general practice and mental health services, with specific sections for mental health history and ACC claims."

Document background
The Health Intake Form is a crucial document used across New Zealand's healthcare sector to gather comprehensive patient information at the initiation of care. This form serves as the foundation for creating patient records and ensuring appropriate medical care while complying with New Zealand's healthcare regulations, including the Privacy Act 2020 and Health Information Privacy Code 2020. The document is designed to capture essential health information, emergency contacts, medical history, and necessary consents, while ensuring accessibility for diverse patient populations. Healthcare providers use this intake form to maintain accurate records, assess patient needs, and establish a basis for ongoing care relationships. The form includes provisions for privacy protection and information sharing in accordance with New Zealand healthcare standards.
Suggested Sections

1. Patient Information: Basic demographic details including full name, date of birth, contact information, and NHI number

2. Emergency Contact Details: Contact information for next of kin or emergency contacts

3. Primary Healthcare Provider: Details of current GP or regular healthcare provider

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

5. Current Medications: List of all current medications, including dosages and frequency

6. Allergies and Reactions: Known allergies to medications, foods, or environmental factors

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

8. Privacy Statement: Information about how personal health information will be collected, used, and protected

9. Consent Declaration: Patient consent for information collection and sharing with relevant healthcare providers

Optional Sections

1. ACC History: Details of any accident-related treatments or claims, used when the practice handles ACC cases

2. Mental Health History: Mental health conditions and treatments, included for practices offering mental health services

3. Lifestyle Factors: Information about diet, exercise, smoking, alcohol consumption, used for comprehensive health assessments

4. Cultural Considerations: Cultural preferences and requirements that may affect healthcare delivery

5. Vaccination History: Record of immunizations, particularly relevant for primary care providers

6. Insurance Information: Health insurance details, used when the practice offers private healthcare services

7. Reproductive Health: Pregnancy history and reproductive health information, included for relevant specialties

Suggested Schedules

1. Medical Conditions Checklist: Comprehensive list of common medical conditions for patient reference

2. Medications List Template: Structured template for listing current medications with dosage instructions

3. Privacy Policy: Detailed privacy policy explaining how health information is handled

4. Consent Forms: Additional specific consent forms for various treatments or information sharing

Authors

Alex Denne

Head of Growth (Open Source Law) @ ¶¶Òõ¶ÌÊÓÆµ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Relevant legal definitions






























Clauses




















Relevant Industries

Healthcare

Medical Services

Mental Health

Primary Care

Specialist Medical Services

Allied Health Services

Private Healthcare

Public Healthcare

Community Health Services

Occupational Health

Relevant Teams

Reception

Administration

Clinical Operations

Medical Records

Compliance

Patient Services

Primary Care

Specialist Care

Quality Assurance

Information Management

Relevant Roles

General Practitioner

Medical Specialist

Practice Manager

Healthcare Administrator

Nurse Practitioner

Registered Nurse

Medical Receptionist

Clinical Director

Privacy Officer

Healthcare Compliance Officer

Patient Services Coordinator

Medical Records Manager

Allied Health Professional

Mental Health Professional

Practice Owner

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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