Legal Templates
Wellness Intake Form

Wellness Intake Form for Canada

Wellness Intake Form Template for Canada

A comprehensive intake form designed for use in Canadian healthcare and wellness settings, compliant with federal and provincial privacy laws including PIPEDA and provincial health information protection acts. This document serves as the initial point of contact between healthcare providers and clients, collecting essential health information, medical history, and necessary consents while maintaining privacy standards. The form includes provisions for emergency contacts, current health status, medication information, and lifestyle factors, structured to meet both clinical requirements and legal obligations in the Canadian healthcare context.

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What is a Wellness Intake Form?

The Wellness Intake Form is a crucial document used by healthcare and wellness providers across Canada to gather essential information from new clients before providing services. This document ensures compliance with Canadian federal and provincial healthcare regulations, including PIPEDA and provincial health information protection acts. The form serves multiple purposes: it collects comprehensive client health information, documents informed consent, establishes the provider-client relationship, and creates a baseline health record. The information gathered through this intake form helps practitioners provide appropriate care while maintaining required medical records and protecting client privacy. It is typically used at the first visit to a healthcare or wellness facility and may need periodic updates to maintain current information.

What sections should be included in a Wellness Intake Form?

1. Personal Information: Basic contact details, demographics, and preferred contact method

2. Emergency Contact Information: Primary and secondary emergency contact details

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

4. Medical History: Past medical conditions, surgeries, hospitalizations, and family health history

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

6. Lifestyle Information: Sleep patterns, exercise habits, stress levels, and dietary information

7. Privacy Policy Acknowledgment: Statement regarding how personal information is collected, used, and protected

8. Consent for Treatment: Informed consent for wellness services and treatments

9. Client Declaration: Declaration that information provided is accurate and complete

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

1. Insurance Information: Details of health insurance coverage, if applicable for the wellness service

2. Specialized Health Questionnaires: Additional health screening tools specific to certain conditions or treatments

3. Pain Assessment: Detailed pain location, intensity, and pattern information for relevant services

4. Preferred Practitioner: Options for selecting specific practitioners or gender preferences

5. Photo/Video Consent: Permission for taking photos/videos for treatment tracking purposes

6. COVID-19 Screening: Temporary section for pandemic-related health screening

What schedules should be included in a Wellness Intake Form?

1. Schedule A - Medical Conditions Checklist: Comprehensive checklist of common medical conditions for patient review

2. Schedule B - Body Chart: Anatomical diagram for marking areas of concern or pain

3. Schedule C - Privacy Policy: Detailed privacy policy and information handling procedures

4. Appendix 1 - Cancellation Policy: Details of appointment cancellation and rescheduling procedures

5. Appendix 2 - Fee Schedule: List of services and associated fees

Authors

Alex Denne

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

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Jurisdiction

Canada

Publisher

Genie AI

Document Type

Intake Form

Sector

Employment

Cost

Free to use
Relevant Industries

Healthcare

Wellness and Alternative Medicine

Mental Health

Physical Therapy

Occupational Health

Sports Medicine

Preventive Care

Holistic Health

Medical Practice Management

Relevant Teams

Legal

Compliance

Healthcare Operations

Administrative Support

Front Desk

Medical Records

Quality Assurance

Privacy and Data Protection

Patient Services

Clinical Operations

Relevant Roles

Healthcare Provider

Wellness Practitioner

Clinic Manager

Medical Office Administrator

Privacy Officer

Compliance Manager

Healthcare Consultant

Naturopathic Doctor

Physiotherapist

Chiropractor

Massage Therapist

Mental Health Counselor

Occupational Therapist

Practice Manager

Intake Coordinator

Industries
Personal Information Protection and Electronic Documents Act (PIPEDA): Federal privacy law that governs the collection, use, and disclosure of personal information in commercial activities, including health and wellness services
Canada Health Act: Federal legislation that sets criteria and conditions for health insurance plans that must be met by provinces and territories to receive federal funding
Provincial Personal Health Information Protection Act: Provincial legislation (varies by province) that specifically governs the collection, use, and disclosure of personal health information
Provincial Health Care Consent Act: Provincial legislation (varies by province) that governs the rules for obtaining informed consent for health treatment
Accessibility for Ontarians with Disabilities Act (AODA): Example of provincial accessibility legislation (Ontario) that requires organizations to meet accessibility standards in their services and documentation
Provincial Regulated Health Professions Act: Provincial legislation that governs regulated health professionals and their scope of practice
Canadian Human Rights Act: Federal law prohibiting discrimination in the provision of services, including health services, based on protected grounds
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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