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Client Intake Form for Health Screenings

I. Client Information

First Name

Last Name

Date of Birth

Gender

Job Title/Role

Department

Phone

Email Address

II. Health History

Do you have any known medical conditions?

If yes, please specify:

Are you currently taking any medications?

If yes, please list:

Have you ever been diagnosed with any of the following? (Check all that apply)

Diabetes

High Blood Pressure

High Cholesterol

Heart Disease

Cancer

Asthma/COPD

Thyroid Disorder

Arthritis

Depression/Anxiety

Other:

Have you had any surgeries or hospitalizations in the past 5 years?

If yes, please specify:

Do you have a family history of any of the following? (Check all that apply)

Heart Disease

Diabetes

Cancer

Stroke

High Blood Pressure

Other:

III. Lifestyle and Habits

How would you describe your physical activity level?

DiabetesSedentary (little to no exercise)

Lightly Active (light exercise 1-2 days/week)

Moderately Active (moderate exercise 3-5 days/week)

Very Active (intense exercise 6-7 days/week)

How many servings of fruits and vegetables do you typically eat per day?

0-1

2-3

4-5

6 or more

Do you smoke or use tobacco products?

Yes

No

Former Smoker

How many alcoholic drinks do you consume per week?

None

1-3

4-7

8 or more

How many hours of sleep do you get on average per night?

Less than 5

5-6

7-8

More than 8

How would you rate your stress level?

Low

Moderate

High

Very High

IV. Health Screening Preferences

Which of the following health screenings are you interested in? (Check all that apply)

Blood Pressure Screening

Cholesterol Panel (Lipid Profile)

Blood Glucose Test (Diabetes Screening)

Body Composition Analysis (BMI, Body Fat Percentage)

Bone Density Test

Vision Screening

Hearing Test

Skin Cancer Screening

Cardiovascular Risk Assessment

Mental Health Screening (Depression/Anxiety)

Nutritional Assessment

Fitness Assessment (Strength, Flexibility, Endurance)

Other:

Are there any specific health concerns you would like to address through these screenings?

If yes, please specify:

Have you participated in any health screenings in the past?

If yes, please describe:

V. Suitability and Preferences

Do you have any allergies or sensitivities that we should be aware of?

If yes, please specify:

Are you comfortable with blood tests or other invasive procedures?

Do you have any physical limitations that might affect your ability to participate in certain screenings?

If yes, please specify:

Would you prefer on-site screenings or appointments at a healthcare facility?

On-Site

Healthcare Facility

No Preference

What is your preferred time for screenings?

Morning

Afternoon

Evening

Do you have any additional comments or questions about the screenings?

VI. Consent and Authorization

I authorize the release of my health information to the Corporate Wellness Program for the purpose of tailoring my wellness plan.

I understand that the results of my health screenings will be kept confidential and used only for wellness program purposes.

I consent to participate in the health screenings offered by the Corporate Wellness Program.

 

Signature

Form Template Insight

The Client Intake Form for Health Screenings is a critical tool for designing a personalized and effective wellness program for employees. Below is a detailed breakdown of the form's sections, their purpose, and the insights they provide:


Section 1: Client Information

Purpose:

This section collects basic demographic and contact information to identify the client and ensure proper communication.


Insights:

  • Job Title/Department: Helps identify if certain roles or departments have higher stress levels or health risks (e.g., sedentary desk jobs vs. physically demanding roles).
  • Contact Information: Ensures the wellness team can follow up with the client regarding screenings, results, or program updates.

Section 2: Health History

Purpose:

To understand the client’s medical background, including existing conditions, medications, and family history.


Insights:

  • Medical Conditions/Medications: Identifies clients who may need specialized screenings (e.g., diabetes, high blood pressure) or accommodations.
  • Family History: Highlights genetic predispositions to conditions like heart disease, diabetes, or cancer, which may warrant early or more frequent screenings.
  • Surgeries/Hospitalizations: Provides context for current health status and potential limitations.

Section 3: Lifestyle and Habits

Purpose:

To assess the client’s daily habits and lifestyle factors that impact overall health.


Insights:

  • Physical Activity Level: Helps tailor fitness assessments or recommend exercise programs.
  • Dietary Habits: Identifies nutritional gaps that could be addressed through dietary counseling or education.
  • Smoking/Alcohol Use: Highlights risk factors for conditions like lung disease, liver issues, or cardiovascular problems.
  • Sleep and Stress Levels: Indicates potential mental health concerns or burnout, which may require stress management interventions.

Section 4: Health Screening Preferences

Purpose:

To determine which screenings the client is interested in and identify specific health concerns they want to address.


Insights:

  • Screening Preferences: Guides the selection of screenings to offer, ensuring they align with client interests and needs.
  • Specific Health Concerns: Helps prioritize screenings that address immediate or high-risk issues (e.g., cardiovascular risk for someone with a family history of heart disease).
  • Past Participation: Provides context on the client’s familiarity with health screenings and their willingness to engage.

Section 5: Suitability and Preferences

Purpose:

To identify any barriers or preferences that may affect the client’s participation in the wellness program.


Insights:

  • Allergies/Sensitivities: Ensures screenings are safe and comfortable (e.g., avoiding latex gloves if allergic).
  • Comfort with Invasive Procedures: Helps tailor the program to the client’s comfort level (e.g., offering non-invasive alternatives to blood tests).
  • Physical Limitations: Identifies clients who may need accommodations (e.g., mobility issues affecting fitness assessments).
  • Time and Location Preferences: Ensures screenings are convenient, increasing participation rates.

Section 6: Consent and Authorization

Purpose:

To obtain legal and ethical consent for participation and data use.


Insights:

  • Confidentiality Agreement: Builds trust by assuring clients their health information will be handled securely.
  • Participation Consent: Ensures clients are fully informed and willing to engage in the program.

Key Benefits of the Form

  1. Personalization: By gathering detailed health and lifestyle information, the wellness program can be tailored to meet individual needs.
  2. Risk Identification: Early detection of risk factors (e.g., high cholesterol, sedentary lifestyle) allows for timely interventions.
  3. Engagement: Including client preferences increases participation and satisfaction with the program.
  4. Compliance: Ensures the program adheres to legal and ethical standards for data privacy and informed consent.
  5. Program Improvement: Data collected from multiple clients can reveal trends (e.g., high stress levels in a department), enabling targeted wellness initiatives.

How to Use the Form Effectively

  1. Pre-Screening: Distribute the form before scheduling screenings to gather necessary information and tailor the program.
  2. Data Analysis: Use aggregated data to identify common health risks and design group wellness initiatives.
  3. Follow-Up: Use the information to provide personalized feedback and recommendations after screenings.
  4. Continuous Improvement: Regularly update the form based on feedback and emerging health trends to keep the program relevant.

By leveraging the insights from this intake form, corporate wellness programs can effectively promote employee health, reduce healthcare costs, and improve overall productivity and morale.

 

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