Health Intake Form Template for Netherlands

A comprehensive medical intake document used in Dutch healthcare settings to collect essential patient information, medical history, and consent for data processing. This form complies with Dutch healthcare regulations, including the Medical Treatment Agreement Act (WGBO) and GDPR requirements. It serves as the initial point of contact between healthcare providers and patients, collecting vital information about medical history, current health status, medications, and lifestyle factors while ensuring proper data protection and patient privacy in accordance with Dutch law.

Generate a Bespoke Document

1. Select your governing law:

2. Enter your key requirements:

Typically:

With ��Ƶ:

£0

Download a Standard Health Intake Form

Download a Netherlands-compliant Health Intake Form or see .

Get template free

Review your own Health Intake Form

Let ��Ƶ identify missing terms, unusual language, compliance issues and more.

Your data doesn't train Genie's AI

You keep IP ownership of your docs

4.6 / 5

4.8 / 5

What is a Health Intake Form?

The Health Intake Form is a fundamental document used across Dutch healthcare settings to establish the initial patient-provider relationship and collect essential health information. This document is typically completed by new patients before their first consultation or when registering with a new healthcare provider. The form includes sections for personal information, medical history, current health status, and necessary GDPR-compliant consent declarations. It must comply with Dutch healthcare legislation, including the Medical Treatment Agreement Act (WGBO), GDPR, and specific Dutch healthcare privacy regulations. The information collected through this form serves as the foundation for creating patient records and ensuring appropriate medical care while maintaining patient privacy and data protection standards.

What sections should be included in a Health Intake Form?

1. Personal Information: Basic identification details including name, date of birth, BSN number, contact information, and emergency contact details

2. Insurance Information: Health insurance provider details, policy number, and coverage information

3. Medical History: Overview of past medical conditions, surgeries, hospitalizations, and chronic conditions

4. Current Health Status: Present health concerns, symptoms, and ongoing treatments

5. Medications: Current medications, dosages, supplements, and known drug allergies

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

7. Lifestyle Information: Information about diet, exercise, smoking, alcohol consumption, and other lifestyle factors

8. Data Processing Consent: GDPR-compliant consent section for processing health data and sharing with relevant healthcare providers

9. Declaration: Patient declaration confirming information accuracy and understanding of data usage

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

1. Mental Health History: Optional section for mental health conditions and treatments, used when the practice includes mental health services

2. Pregnancy History: For practices dealing with women's health or when relevant to current treatment

3. Occupational Health: Details about work-related health risks and concerns, used when occupational health is relevant

4. Sports and Physical Activity: Detailed section about sports participation and exercise routines, relevant for sports medicine or physiotherapy practices

5. Cultural/Religious Considerations: Special healthcare considerations related to cultural or religious beliefs, included when relevant to the healthcare setting

6. Alternative Medicine History: Information about alternative treatments and therapies, used in integrative medicine practices

What schedules should be included in a Health Intake Form?

1. Privacy Notice: Detailed information about how personal data is collected, processed, stored, and shared

2. Medical Conditions Checklist: Comprehensive checklist of common medical conditions for patient reference

3. Medication List Template: Structured template for listing current medications and dosages

4. Patient Rights Information: Document outlining patient rights under Dutch healthcare law

5. Practice Information: Details about the healthcare practice, including contact information, emergency procedures, and complaint procedures

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents

Cost

Free to use

Find the exact document you need

No matches found.

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.

������Ƶ

How a Fast-Growing Real Estate Company Uses ������Ƶ to Save $50,000 Per Year in Legal Fees

Generate a Bespoke Document

Download a Standard Health Intake Form

Review your own Health Intake Form

What is a Health Intake Form?

What sections should be included in a Health Intake Form?

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

What schedules should be included in a Health Intake Form?

Authors

Alex Denne

Jurisdiction

Publisher

Document Type

Sector

Cost

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

�ұ�Ծ���’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security:

Use Cases

��Ƶ

How a Fast-Growing Real Estate Company Uses ��Ƶ to Save $50,000 Per Year in Legal Fees

�ұ�Ծ��’s Security Promise