Holistic Intake Form

Holistic Intake Form Template for Netherlands

Create a bespoke document in minutes, or upload and review your own.

4.6 / 5

4.8 / 5

Let's create your Holistic Intake Form

1. Select your governing law and document type:

2. Enter your key requirements:

3. Create your document to edit, review or download

Get your first 2 documents free

Your data doesn't train Genie's AI

You keep IP ownership of your information

Key Requirements PROMPT example:

"I need a Holistic Intake Form for my new integrative medicine clinic opening in Amsterdam in March 2025, with emphasis on collecting both conventional medical history and alternative therapy experiences, including sections for Traditional Chinese Medicine and naturopathy treatments."

Document background

The Holistic Intake Form serves as an essential first point of contact between healthcare providers and patients in the Netherlands, designed to gather comprehensive information about a patient's health status, medical history, and wellness goals. This document is typically used at the initial consultation in various healthcare settings, from complementary medicine practices to integrated health clinics. It complies with Dutch healthcare regulations, including the Medical Treatment Contracts Act (WGBO), the General Data Protection Regulation (AVG/GDPR), and the Healthcare Quality, Complaints and Disputes Act (Wkkgz). The form includes sections for personal information, medical history, lifestyle factors, and consent declarations, ensuring both legal compliance and thorough patient assessment. It serves as a foundation for creating personalized treatment plans while maintaining proper medical documentation as required by Dutch law.

Suggested Sections

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

2. Privacy Notice and Consent: GDPR-compliant privacy statement and consent for data processing, including specific consent for sharing information with other healthcare providers if necessary

3. Current Health Concerns: Primary reasons for seeking treatment, current symptoms, and health goals

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

5. Medication and Supplements: Current medications, supplements, herbs, and any known drug allergies or reactions

6. Family Medical History: Relevant family health history and genetic predispositions

7. Lifestyle Assessment: Diet, exercise, sleep patterns, stress levels, occupation, and daily routines

8. Mental and Emotional Health: Current mental health status, stress levels, emotional well-being, and relevant history

9. Healthcare Provider Information: Details of other healthcare providers involved in the client's care

10. Declaration and Signature: Client's confirmation that provided information is accurate and consent for treatment

Optional Sections

1. Pregnancy and Fertility: Section for individuals who are pregnant, trying to conceive, or have reproductive health concerns

2. Pain Assessment: Detailed pain evaluation section for clients with chronic pain or specific pain conditions

3. Traditional Medicine Use: Section for recording use of traditional medicines or cultural healing practices

4. Sports and Physical Activity: Detailed section for active individuals or athletes regarding training and performance

5. Environmental Factors: Section addressing environmental exposures, sensitivities, and living conditions

6. Dietary Restrictions: Detailed section for those with specific dietary requirements or restrictions

7. Insurance Information: Section for recording health insurance details if applicable to the treatment

Suggested Schedules

1. Pain Diagram: Body diagram for marking areas of pain or discomfort

2. Medication List Template: Detailed template for listing all current medications and supplements

3. Food Diary Template: Template for recording dietary intake

4. Symptom Tracking Sheet: Template for monitoring symptoms over time

5. Privacy Policy: Detailed GDPR-compliant privacy policy

6. Treatment Consent Form: Detailed informed consent document for specific treatments

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 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

Alternative Medicine

Complementary Medicine

Wellness and Prevention

Mental Health

Physical Therapy

Naturopathy

Integrative Medicine

Behavioral Health

Preventive Care

Relevant Teams

Legal

Compliance

Clinical Operations

Patient Care

Quality Assurance

Administrative Support

Medical Records

Patient Experience

Healthcare Operations

Risk Management

Data Protection

Relevant Roles

Healthcare Provider

Complementary Medicine Practitioner

Holistic Health Practitioner

Naturopath

Physical Therapist

Mental Health Professional

Wellness Consultant

Integrative Medicine Physician

Practice Manager

Clinical Administrator

Compliance Officer

Healthcare Legal Advisor

Quality Assurance Manager

Patient Care Coordinator

Intake Specialist

Find the exact document you need

Massage Client Consultation Form

A GDPR-compliant massage therapy consultation and consent form for use in the Netherlands, combining client health assessment with legal requirements.

tiktok���˰�

How a Sales & Marketing Lead uses tiktok���˰� to reduce contract drafting time by 95%

Let's create your Holistic Intake Form

Authors

Alex Denne

Find the exact document you need

Massage Client Consultation Form

Holistic Intake Form

Salon Intake Form

New Patient Intake Form

Basic Intake Form

Yoga Intake Form

Health Intake Form

Marketing Intake Form

Intake Form

Project Intake Form

Consent For Massage Therapy Form

Therapy Intake Form

Marketing Client Intake Form

Event Planning Intake Form

Massage Client Intake Form

Inventory Intake Form

Vehicle Intake Form

Real Estate Buyer Intake Form

Consulting Intake Form

Order Intake Form

Bookkeeping Client Intake Form

Creative Intake Form

Lead Intake Form

Vendor Intake Form

Clinical Intake Form

Procurement Intake Form

Patient Intake Form

Download our whitepaper on the future of AI in Legal

�ұ�Ծ���’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security

Innovation in privacy:

Want to know more?

Use Cases

tiktok��˰�

How a Sales & Marketing Lead uses tiktok��˰� to reduce contract drafting time by 95%

�ұ�Ծ��’s Security Promise