Wellness Intake Form

Wellness Intake Form for Philippines

Wellness Intake Form Template for Philippines

A comprehensive intake form designed for wellness facilities operating in the Philippines, compliant with the Data Privacy Act of 2012 (RA 10173) and relevant healthcare regulations. This document serves as the initial point of contact between the wellness provider and client, collecting essential health information, medical history, lifestyle factors, and necessary consents. It includes provisions for data protection, emergency contacts, and specific health assessments while adhering to Philippine healthcare documentation requirements and privacy standards.

Your data doesn't train Genie's AI

You keep IP ownership of your information

Generate a Bespoke Document

1. Select your governing law:

2. Enter your key requirements:

3. Create your document to edit, review or download

Download a Standard Template

Get our Philippines-compliant Wellness Intake Form

4.6 / 5

4.8 / 5

Alternatively: Run an advanced review of an existing
Wellness Intake Form

Let ��Ƶ's market-leading legal AI identify missing terms, unusual language, compliance issues and more - in just seconds.

What is a Wellness Intake Form?

The Wellness Intake Form is a fundamental document used by wellness facilities and healthcare providers in the Philippines to gather comprehensive client information before providing services. This form ensures compliance with Philippine regulations, particularly the Data Privacy Act of 2012 and healthcare documentation requirements. It serves as both a medical record and a legal document, collecting vital information about the client's health status, medical history, lifestyle factors, and emergency contacts. The form includes necessary consent declarations and privacy notices, making it essential for risk management and quality care delivery. Wellness providers use this intake form to assess client needs, identify potential contraindications, and maintain accurate records as required by Philippine law.

What sections should be included in a Wellness Intake Form?

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

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

3. Current Health Status: Present health conditions, symptoms, and immediate health concerns

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

5. Medications and Supplements: Current medications, supplements, and allergies

6. Lifestyle Information: Sleep patterns, exercise habits, stress levels, and occupation-related health factors

7. Family Medical History: Relevant family health conditions and hereditary concerns

8. Privacy Notice: Information about how personal data will be collected, used, and protected as per Data Privacy Act

9. Consent and Declaration: Client's signature confirming information accuracy and consent for treatment

What sections are optional to include in a Wellness Intake Form?

1. Nutrition Assessment: Detailed dietary habits and nutritional concerns, used when nutrition counseling is offered

2. Physical Activity Readiness: Assessment of ability to engage in physical activities, required for fitness-related services

3. Mental Health Screening: Basic mental health assessment, included when offering stress management or counseling services

4. Traditional Medicine History: Previous experience with traditional Filipino healing practices, relevant when offering alternative treatments

5. Pregnancy and Reproductive Health: Specific section for female clients of reproductive age, when relevant to treatment

6. Pain Assessment: Detailed pain location and intensity evaluation, used for massage or physical therapy services

7. Insurance Information: Health insurance details, included if the facility accepts insurance payments

What schedules should be included in a Wellness Intake Form?

1. Appendix A: Detailed Health Questionnaire: Comprehensive questionnaire for specific health conditions

2. Appendix B: Treatment Consent Forms: Specific consent forms for different types of treatments offered

3. Appendix C: Privacy Policy: Detailed privacy policy and data protection measures in compliance with RA 10173

4. Appendix D: Liability Waiver: Standard liability waiver for wellness services

5. Appendix E: Service Menu: List of available wellness services and their descriptions

6. Appendix F: Cancellation Policy: Detailed policy regarding appointment cancellations and refunds

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

Cost

Free to use

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Wellness and Spa

Alternative Medicine

Physical Therapy

Mental Health

Fitness and Recreation

Holistic Health

Corporate Wellness

Medical Tourism

Preventive Healthcare

Relevant Teams

Operations

Clinical Services

Administration

Front Office

Compliance and Legal

Quality Assurance

Records Management

Customer Service

Risk Management

Privacy and Data Protection

Relevant Roles

Wellness Center Manager

Healthcare Administrator

Spa Director

Physical Therapist

Alternative Medicine Practitioner

Wellness Consultant

Medical Records Officer

Compliance Officer

Privacy Officer

Front Desk Coordinator

Wellness Program Coordinator

Clinical Director

Health Information Manager

Quality Assurance Manager

Risk Management Officer

Find the exact document you need

No matches found.

Pt Intake Form

A Philippine-compliant physical therapy intake form for collecting patient information, medical history, and treatment consent under local healthcare regulations.

��������Ƶ

How Cambridge United Uses ��������Ƶ to Speed Up Player Signings and Slash Legal Costs

Generate a Bespoke Document

Download a Standard Template

What is a Wellness Intake Form?

What sections should be included in a Wellness Intake Form?

What sections are optional to include in a Wellness Intake Form?

What schedules should be included in a Wellness Intake Form?

Authors

Alex Denne

Jurisdiction

Publisher

Document Type

Sector

Cost

Find the exact document you need

Pt Intake Form

Hypnosis Intake Form

Veterinary Patient Intake Form

Seller Intake Form (Real Estate)

Massage Client Consultation Form

Mediation Intake Form

Health Coach Intake Form

Basic Intake Form

Computer Repair Intake Form

Yoga Intake Form

Naturopathic Intake Form

Event Intake Form

Chiropractic Patient Intake Form

Legal Intake Form

Event Planning Client Intake Form

Nutrition Intake Form

Project Intake Form

Massage Form

General Intake Form

Therapy Intake Form

Real Estate Lead Intake Form

Real Estate Client Intake Form

Program Intake Form

Phone Intake Form

Marketing Client Intake Form

Intake Referral Form

Initial Intake Form

Client Intake Assessment Form

Nonprofit Intake Form

Financial Coaching Intake Form

Virtual Assistant Intake Form

Massage Client Intake Form

Home Care Intake Form

Case Intake Form

Referral Intake Form

Biopsychosocial Intake Form

Real Estate Buyer Intake Form

Marriage Counseling Intake Form

Financial Intake Form

�ұ�Ծ���’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security:

Use Cases

Generate Legal Docs Free

��Ƶ

How Cambridge United Uses ��Ƶ to Speed Up Player Signings and Slash Legal Costs

�ұ�Ծ��’s Security Promise