Health & wellness intake
template.
Plan purposeful intake questions and a private handoff to the person who reviews them.
Designed for: Guests completing service intake.
Collect information with a clear, private next step.
An intake form should help the responsible professional prepare for the service. It should not become a catch-all questionnaire that collects sensitive answers nobody knows how to handle. Start by identifying what the service needs and who will review each type of information.
This outline separates guest details, service context, reviewed intake questions, privacy information, and any required acknowledgment. It deliberately does not provide clinical screening questions or decide which health details are appropriate for your practice.
What to decide before
you build the form.
Have the professional choose the questions.
Use the actual service and its review process to decide what to ask. A question flag can bring an answer to attention, but it does not diagnose, assess suitability, or give clearance for a service. Assign a qualified reviewer where the workflow requires one.
Limit the reception handoff.
Reception may need to know that review is outstanding without seeing every answer. Define access and communication practices before collecting the information. Keep sensitive details out of reminder texts and public conversations in the lobby.
Confirm your production requirements.
Understand the role of your organization, the applicable privacy requirements, and any required BAA arrangements. The product’s stated infrastructure scope does not by itself establish that a particular intake workflow is appropriate or compliant.
Give this document a clear job.
This is an intake-planning outline, not medical advice, treatment consent, a diagnosis, or a ready-to-use clinical questionnaire. Participation and treatment decisions may require separate documents and professional processes. Add only the reviewed material needed for your service.
Try the awkward cases.
Use fictional answers to test a new guest, a returning guest, a private question, and an answer requiring review. Confirm that the right person can see what they need and that appointment staff can identify an outstanding task without exposing the details.
Once the wording and flow are reviewed, publish a controlled version. Keep the signed version with its record, and give the team a clear way to find a participant, resolve a missing signature, and retrieve the PDF later.
Read the publishing guideA few useful answers.
Does this contain a medical questionnaire?
No. It organizes an intake flow but does not prescribe clinical questions. The responsible professional must choose the content for the actual service.
Does a flagged answer approve or reject an appointment?
No. A flag is a prompt for staff review. It is not a medical assessment or a determination about whether a service should proceed.
Is every health-related intake subject to HIPAA?
Not automatically. HIPAA’s application depends on the organization’s actual role and activities. Review your setup and obligations before collecting regulated information; the spa guide links to HHS’s primary guidance.