Health Coach Intake Form

Health Coach Intake Form Template for South Africa

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Key Requirements PROMPT example:

"I need a Health Coach Intake Form for my virtual wellness practice launching in January 2025, compliant with POPIA and suitable for online completion, with strong emphasis on data protection and digital record keeping."

Document background

The Health Coach Intake Form is an essential document for health and wellness professionals operating in South Africa who provide coaching services to clients. This document is typically used at the commencement of a new client relationship to gather comprehensive information about the client's health status, goals, and medical history. The form must comply with South African regulations, particularly POPIA for data protection and relevant healthcare legislation. It serves multiple purposes: collecting necessary client information, establishing the scope of services, documenting informed consent, and creating a baseline for the coaching relationship. The document includes various assessments of client health and lifestyle factors while clearly delineating the boundaries between health coaching and medical advice.

Suggested Sections

1. Personal Information: Client's basic details including full name, ID number, contact information, and emergency contact details

2. Medical History: Current health conditions, past surgeries, medications, allergies, and family health history

3. Lifestyle Assessment: Current diet, exercise habits, sleep patterns, stress levels, and work-life balance

4. Goals and Expectations: Client's specific health and wellness goals, timeline expectations, and motivation for seeking coaching

5. Current Health Status: Present health concerns, energy levels, digestive health, and other relevant health indicators

6. Privacy Notice: POPIA-compliant explanation of how personal information will be collected, used, stored, and protected

7. Consent Declaration: Client's acknowledgment and consent for information collection and coaching relationship

8. Disclaimer: Clear statement that health coaching is not medical advice or treatment, and coach's scope of practice

Optional Sections

1. Dietary Preferences: Detailed section for clients seeking nutrition-focused coaching, including food preferences, restrictions, and eating patterns

2. Physical Activity Assessment: Detailed section for fitness-focused clients, including exercise history, injuries, and movement capabilities

3. Stress Management: Additional questions about stress factors and coping mechanisms for clients focusing on mental wellness

4. Sleep Assessment: Detailed sleep patterns and habits for clients with sleep-related goals

5. Payment Information: Section for billing details and preferred payment methods if not handled through a separate system

Suggested Schedules

1. Schedule A: Health History Questionnaire: Detailed medical history form for comprehensive health background

2. Schedule B: PAR-Q Form: Physical Activity Readiness Questionnaire for clients interested in exercise programming

3. Schedule C: Food and Mood Journal Template: Template for tracking food intake and corresponding energy/mood levels

4. Appendix 1: Coaching Package Details: Description of available coaching packages, sessions, and included services

5. Appendix 2: Emergency Protocols: Procedures to follow in case of health emergencies during coaching sessions

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

Fitness

Alternative Medicine

Nutrition

Personal Development

Professional Services

Sports and Recreation

Relevant Teams

Legal

Compliance

Client Relations

Wellness Services

Healthcare Services

Operations

Administrative Services

Risk Management

Relevant Roles

Health Coach

Wellness Coach

Nutrition Coach

Fitness Coach

Lifestyle Coach

Wellness Coordinator

Practice Manager

Compliance Officer

Client Relations Manager

Wellness Program Director

Holistic Health Practitioner

Wellness Consultant

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