Corporate Wellness Programs: Health Screenings Client Intake Form

I. Company Information

Company Name

Company Address

City/Suburb

State/Province

Postal/Zip Code


Contact Person (Wellness Coordinator/HR)

Contact Phone


Contact Email

Number of Employees

Industry


Company Mission/Values

Current Health and Wellness Initiatives

II. Wellness Program Objectives

What are the primary objectives of your corporate wellness program? (Check all that apply)

What specific outcomes do you hope to achieve with health screenings?

What is your desired timeframe for implementing the health screenings?

What is your approximate budget for the health screenings?

III. Employee Demographics and Health Profile

What is the age range of your employees?

What is the gender breakdown of your employees?

What are the common job roles/physical demands within your company?

Are there known prevalent health conditions or risk factors within your employee population? (e.g., sedentary work, stress, physical labor, chemical exposure, etc.)

Do you have any existing employee health data or reports?

IV. Screening Options and Suitability

Please select the screenings you are interested in and answer the following questions to help us assess suitability:

Screening Option

Your Answer

Basic Health Screening (Blood Pressure, BMI, Cholesterol, Glucose):

Are you concerned about general cardiovascular health risks within your employee population?

 

Do your employees generally have sedentary lifestyles?

 

Are you wanting basic overall health metrics for your employee population?

 

Comprehensive Blood Panel (Lipid Panel, Complete Blood Count, Comprehensive Metabolic Panel, Thyroid Function):

Do you have employees with known chronic conditions?

 

Do you require an in-depth review of metabolic and organ health?

 

Cancer Screening (Prostate, Breast, Colorectal, Skin, etc. - Specify which ones):

Is there a history of cancer within your employees or their families?

 

Are you looking to provide targeted screenings based on gender and age related cancer risks?

 

Mental Health Screening (Depression, Anxiety, Stress):

Is workplace stress a concern in your company?

 

Have employees expressed concerns regarding mental health?

 

Fitness Assessment (Strength, Flexibility, Cardiovascular Endurance):

Do you want to encourage physical activity within your workforce?

 

Are many employees involved in physical labor, or do they require fitness assesments for specific job roles?

 

Nutritional Assessment:

Are you concerned about employee dietary habits?

 

Do you want to promote a culture of healthy eating?

 

Vision Screening:

Are a high number of employee's performing close detailed computer or other vision intensive work?

 

Is your companies insurance lacking vision coverage?

 

Hearing Screening:

Do you have any work environments with high noise levels?

 

Are you attempting to protect employees who work around machinery?

 

Lung Function Test

Does your industry have employees with high exposure to particulate matter or smoke?

 

Are you wanting to evaluate respiratory health?

 


What are your preferences regarding:


On-site or off-site screenings?

Individual or group appointments?

Electronic or paper-based reporting?

How will the screening results be shared with employees?

V. Follow-Up and Program Integration

Are you interested in follow-up services, such as:


Health Coaching?

Educational Workshops?

Referrals to Medical Professionals?

Ongoing wellness programs?

How will the screening results be integrated into your overall wellness program?

Are you intending on providing employee incentives for participating in the wellness screenings?

VI. Confidentiality and Data Security

How important is data security, and what measures do you require to ensure employee confidentiality?

Do you have specific data privacy policies in place?

VII. Additional Information

Please provide any additional information or specific requirements you would like us to consider:


Please sign below to indicate that the information provided is accurate to the best of your knowledge.


Company Representative Signature:

Form Template Insight

Please remove this form template insight section before publishing.


Let's break down the detailed insights into this Corporate Wellness Programs: Health Screenings Client Intake Form, section by section:


I. Company Information:


Purpose: This section establishes the foundation by gathering essential contact and organizational details.

Insights:

  • Knowing the company's industry helps understand potential occupational health risks (e.g., manufacturing vs. tech).
  • Employee count is crucial for planning logistics and estimating costs.
  • Understanding the company's mission/values and current wellness initiatives provides context for tailoring the program to align with their culture.
  • Knowing the contact person, and their role, allows for proper communication throughout the process.

II. Wellness Program Objectives:


Purpose: This section clarifies the company's goals for implementing the wellness program and health screenings.

Insights:

  • Identifying primary objectives allows for the selection of relevant screenings and follow-up services.
  • Understanding desired outcomes helps measure the program's success.
  • Timeframe and budget information are essential for planning and resource allocation.
  • This section allows the wellness provider to determine if the client's goals align with the services the wellness provider offers.

III. Employee Demographics and Health Profile:


Purpose: This section gathers information about the employee population to assess their health needs and risks.

Insights:

  • Age and gender demographics influence the selection of appropriate screenings (e.g., cancer screenings).
  • Job roles and physical demands help identify potential occupational health risks.
  • Prevalent health conditions or risk factors provide valuable insights for targeted interventions.
  • Existing health data, if available, can inform the program's design and evaluation.

IV. Screening Options and Suitability:


Purpose: This section allows the client to select desired screenings and provides a structured way to assess their suitability.

Insights:

  • The detailed questions for each screening option help determine if the screening is appropriate for the company's needs and employee population.
  • This section encourages the client to think critically about their employees' health risks.
  • Preferences regarding screening logistics (on-site/off-site, individual/group, reporting) are essential for planning.
  • The question regarding how results will be shared is vital for adhering to privacy laws, and ensuring that the client has a plan for how to handle the data.
  • Asking about employee incentives can help predict employee participation.

V. Follow-Up and Program Integration:


Purpose: This section explores the client's interest in follow-up services and how the screenings will be integrated into their overall wellness program.

Insights:

  • Follow-up services, such as health coaching and educational workshops, can enhance the program's effectiveness.
  • Integrating screening results into a broader wellness program ensures a holistic approach to employee health.
  • Knowing how screening results will be used allows for the screening program to be designed to provide the information in a useful format.
  • Asking about ongoing wellness programs, allows for the wellness provider to offer more services, and to build a long term client relationship.

VI. Confidentiality and Data Security:


Purpose: This section addresses the critical issue of data privacy and security.

Insights:

  • Understanding the client's data security requirements is essential for building trust and ensuring compliance with privacy regulations.
  • Inquiring about existing data privacy policies helps identify potential gaps and ensure alignment.
  • This section protects the wellness provider, and the corporate client, from potential legal issues.

VII. Additional Information:


Purpose: This section provides an opportunity for the client to share any additional information or specific requirements.

Insights:

  • This section allows for flexibility and customization of the program to meet the client's unique needs.
  • It also allows the client to bring up any potential issues, or concerns, that were not covered in the previous sections.

Overall Insights:

  • Comprehensive Data Gathering: The form covers a wide range of aspects, ensuring a thorough understanding of the client's needs.
  • Structured Assessment: The questions are designed to guide the client through a logical process of evaluating their needs and selecting appropriate screenings.
  • Emphasis on Suitability: The form focuses on assessing the suitability of screenings for the employee population, ensuring that the program is effective and relevant.
  • Focus on Privacy: The form shows that the wellness provider is concerned about, and is prepared to handle, sensitive health information.
  • Customization: The form provides a strong foundation for customization, allowing for the creation of tailored wellness programs.

By using this form and analyzing the insights it provides, wellness providers can develop effective and impactful corporate wellness programs that meet the specific needs of their clients.



What are the particular pain points you're hoping this form template can address? Let's tailor it to provide the perfect fix! Edit this Corporate Wellness Programs: Health Screenings Client Intake Form
Take control of your data like never before! Design your own forms with Zapof and integrate intelligent tables that automate calculations and simplify analysis.

You’ve got great taste — here’s more to explore:

Your template playground is waiting! 🛝 Explore these collections!

This form is protected by Google reCAPTCHA. Privacy - Terms.
 
Built using Zapof