Zapof

Holistic Wellness Telehealth
Client Intake Form

I. Personal Information

First Name

Last Name

Date of Birth

Gender

Phone Number

Email Address

Mailing Address

Last Name

Last Name

Last Name

Emergency Contact Name

Emergency Contact Phone

II. Health History

Primary Care Physician Name

Primary Care Physician Phone

Please list any current medical conditions.

Please list any past medical conditions.

Please list any current medications or supplements.

Do you have any known allergies? (Food, medications, environmental)

Have you experienced any recent injuries or surgeries?

Are you currently pregnant or breastfeeding? (If applicable)

Do you experience any chronic pain?

If yes, please describe.

Do you have any mental health diagnoses or concerns? (Anxiety, depression, etc.)

Have you ever been diagnosed with an eating disorder?

Do you have any sleep disorders or experience difficulty sleeping?

Do you have any history of substance abuse?

III. Lifestyle and Wellness Goals

What are your primary wellness goals? (Check all that apply)

Weight Management

Increased Energy

Improved Fitness

Stress Reduction

Improved Sleep

Enhanced Mental Clarity

Nutritional Guidance

Mindfulness and Meditation

Improved Flexibility and Mobility

Other (Please specify):

What areas of your life would you like to improve? (Check all that apply)

Physical Health

Mental Health

Emotional Well-being

Nutrition

Fitness

Stress Management

Sleep

Relationships

Work-Life Balance

What is your current activity level?

Sedentary

Lightly Active (1-3 days/week)

Moderately Active (3-5 days/week)

Very Active (6-7 days/week)

Describe your typical daily diet.

Do you have any dietary restrictions or preferences?

Vegetarian

Vegan

Gluten-free

Other (Please specify):

How many hours of sleep do you typically get per night?

How would you rate your current stress level? (1-10, 1 being low, 10 being high)

Do you currently engage in any mindfulness or meditation practices?

What are your biggest obstacles to achieving your wellness goals?

IV. Wellness Modality Preferences

Which wellness modalities are you most interested in? (Check all that apply)

Personalized Fitness Programs

Nutritional Counseling and Meal Planning

Mindfulness and Meditation Coaching

Stress Management Techniques

Yoga and Pilates

Guided Relaxation and Breathwork

Lifestyle Coaching

Other (Please specify):

What type of fitness activities do you enjoy?

Cardio

Strength training

Yoga

Other:

Are you interested in group or individual coaching sessions?

What is your preferred method of online communication?

Video calls

phone calls

messaging

What is your preferred time of day for sessions?

What is your budget for wellness programs?

V. Technology and Environment

Do you have reliable internet access?

Do you have a device suitable for video conferencing? (Computer, tablet, smartphone)

Do you have a quiet and private space for online sessions?

Do you have any physical limitations that might affect your ability to participate in online fitness or movement programs?

If yes, please describe.

VI. Program Suitability Questions

Are you currently under the care of a medical professional for any health condition?

If yes, have you received clearance to participate in a wellness program?

Are you seeking treatment for any mental health disorder?

If yes, are you currently under the care of a mental health professional?

Do you understand that online wellness programs are not a substitute for medical or mental health treatment?

Do you understand that you are responsible for communicating any changes in your health or well-being to your wellness coach?

Are you willing to commit to the program and actively participate in sessions and activities?

What are your expectations for this wellness program?

Are you aware that some fitness programs can involve strenuous activity, and that you are responsible for monitoring your own level of exertion?

Are you willing to follow dietary guidelines provided by the nutritionist?

Are you comfortable with online technology and video conferencing?

VII. Consent and Agreement

I understand and agree to the terms and conditions of the Holistic Wellness Telehealth program.

I consent to the collection and use of my personal and health information for the purpose of providing wellness services.

I acknowledge that I have answered all questions truthfully and to the best of my ability.

Signature

Client Intake Form Insights

Please remove this client intake form insights section before publishing.


Important Considerations:

  • Privacy: Ensure you have a secure platform for storing and transmitting client information.
  • Legal Compliance: Consult with legal professionals to ensure your intake form and practices comply with relevant privacy laws (e.g., HIPAA, GDPR).
  • Customization: This form can be customized to fit your specific niche and the programs you offer.
  • Clarity: Use clear and concise language that is easy for clients to understand.
  • Follow-Up: Schedule a consultation to review the client's intake form and discuss their goals and program suitability.

Let's dissect this Holistic Wellness Telehealth Client Intake Form to understand its detailed insights and purpose:


Let's dissect this Holistic Wellness Telehealth Client Intake Form to understand its detailed insights and purpose:


1. Comprehensive Data Gathering:


Personal Information:

  • This section establishes basic client identification and contact details, crucial for communication and record-keeping.
  • Emergency contact information is vital for safety, particularly in fitness or health-related programs.

Health History:

  • This is the cornerstone of ensuring program suitability and safety.
  • It uncovers potential contraindications for certain activities or dietary recommendations.
  • Understanding existing medical conditions, medications, and allergies is essential to prevent adverse reactions.
  • Mental health inquiries are included to provide a holistic view and address potential co-occurring issues.
  • It helps to understand if the client is already recieving care from other medical professionals.

Lifestyle and Wellness Goals:

  • This section delves into the client's motivations and aspirations.
  • It identifies their specific areas of interest and helps tailor the program to their individual needs.
  • Understanding their current activity level, dietary habits, and sleep patterns provides a baseline for progress tracking.
  • Identifying obstacles allows for proactive problem-solving and support.
  • It allows the wellness provider to know what the client is looking for, and if they can provide it.

Wellness Modality Preferences:

  • This section ensures that the client's preferences are considered when designing their program.
  • It allows for customization and personalization, which increases client engagement and adherence.
  • Understanding their preferred communication methods and session times optimizes the online experience.
  • It also helps to determine if the clients budget aligns with the services offered.

Technology and Environment:

  • This section addresses the practical aspects of online telehealth.
  • It ensures that the client has the necessary technology and a suitable environment for successful participation.
  • It helps identify potential technical difficulties that may need to be addressed.
  • It ensures that there will be minimal disruptions during online sessions.

Program Suitability Questions:

  • This is a critical section for risk assessment and informed consent.
  • It reinforces that online wellness programs are not a substitute for medical or mental health treatment.
  • It emphasizes the client's responsibility for self-monitoring and communication.
  • It sets realistic expectations and ensures that the client is aware of the potential risks and benefits of the program.
  • It helps to determine if it is ethical to proceed with the client.

Consent and Agreement:

  • This section formalizes the client's agreement to participate in the program and consent to the use of their information.
  • It provides legal protection for the wellness provider.

2. Key Insights and Benefits:

  • Personalized Approach: The form facilitates a highly personalized approach to wellness coaching, ensuring that programs are tailored to individual needs and preferences.
  • Risk Management: The health history and program suitability questions help identify potential risks and contraindications, minimizing the likelihood of adverse events.
  • Effective Communication: The form establishes a clear communication channel between the client and the wellness provider.
  • Progress Tracking: The baseline data collected in the lifestyle and wellness goals section allows for effective progress tracking and evaluation.
  • Client Empowerment: By involving the client in the program design and decision-making process, the form empowers them to take ownership of their wellness journey.
  • Legal and Ethical Considerations: The consent and agreement section ensures that the wellness provider is operating within legal and ethical guidelines.
  • Efficiency: Having all of this information collected at the beginning of the client/coach relationship helps to increase efficiency, and allows the coach to spend more time working with the client.

3. Potential Improvements and Considerations:

  • Digital Integration: Consider integrating the form with your online platform for seamless data collection and storage.
  • Accessibility: Ensure the form is accessible to clients with disabilities, such as those with visual or auditory impairments.
  • Cultural Sensitivity: Review the language and questions to ensure they are culturally sensitive and inclusive.
  • Regular Updates: Periodically review and update the form to reflect changes in best practices and legal requirements.
  • Conditional Logic: Implement conditional logic in digital versions of the form to streamline the process and only ask relevant questions. For example, if a client answers "yes" to a specific medical condition, additional related questions can appear.
  • Client Feedback: Ask for feedback from clients on the intake process to identify areas for improvement.

By understanding the detailed insights and purpose of each section, you can effectively use this intake form to build strong client relationships and deliver impactful wellness programs.


To configure an element, select it on the form.

To add a new question or element, click the Question & Element button in the vertical toolbar on the left.