Clinical Intake Form Template for Netherlands

A comprehensive medical intake document used in Dutch healthcare settings to collect essential patient information, medical history, and obtain necessary consents in compliance with Dutch healthcare laws (WGBO) and EU data protection regulations (GDPR). The form serves as the initial point of contact between healthcare providers and patients, capturing crucial medical information, consent for treatment, and authorization for data processing. It includes sections for personal information, medical history, current health status, and relevant privacy notices, all structured to meet Dutch healthcare documentation requirements.

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What is a Clinical Intake Form?

The Clinical Intake Form is a fundamental document used across Dutch healthcare settings to initiate the provider-patient relationship and ensure compliance with legal and medical requirements. It serves as the primary tool for collecting essential patient information at the first point of contact, incorporating elements required by the Medical Treatment Agreement Act (WGBO) and the General Data Protection Regulation (GDPR). The form is designed to gather comprehensive medical information, including patient history, current health status, and necessary consents, while ensuring that all data collection and processing meets Dutch healthcare standards. This document is particularly important as it forms the basis for the treatment agreement between healthcare providers and patients, as required by Dutch law, and ensures proper documentation of patient information and consent.

What sections should be included in a Clinical Intake Form?

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

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

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

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

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

6. Allergies and Reactions: Known allergies to medications, substances, or materials and type of reactions

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

8. Lifestyle Information: Smoking, alcohol use, exercise habits, and other lifestyle factors

9. Privacy Statement: GDPR-compliant privacy notice explaining how personal data will be processed

10. Consent Declaration: Patient's consent for treatment and data processing as per WGBO requirements

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

1. Mental Health History: Optional section for mental health conditions and treatments, used when mental health services may be relevant

2. Occupational Health Information: Details about work-related health risks and concerns, included when occupational health is relevant

3. Pregnancy and Gynecological History: For female patients when relevant to current care

4. Cultural/Religious Considerations: Special cultural or religious considerations that may affect treatment, included when relevant to patient care

5. Language and Communication Preferences: For patients who may require interpretation services or have specific communication needs

6. Social Support Assessment: Information about living situation and support systems, included for elderly or vulnerable patients

What schedules should be included in a Clinical Intake Form?

1. Medication List Template: Detailed template for listing current medications with dosage schedules

2. Privacy Notice: Detailed GDPR-compliant privacy notice explaining data processing practices

3. Patient Rights Document: Summary of patient rights under Dutch healthcare laws

4. Consent Forms: Specific consent forms for various treatments or data processing activities

5. Medical History Questionnaire: Detailed questionnaire for systematic collection of medical history

Authors

Alex Denne

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

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Generate a Bespoke Document

Download a Standard Clinical Intake Form

Review your own Clinical Intake Form

What is a Clinical Intake Form?

What sections should be included in a Clinical Intake Form?

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

What schedules should be included in a Clinical Intake Form?

Authors

Alex Denne

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