Patient Intake Form
A patient intake form is about this visit, not the whole history. What's wrong, how long, what's been tried, and - the question most forms skip - what the patient is hoping for.
For clinics, practices and healthcare providers.
Ask what they're worried about
Patients arrive with a symptom and a fear, and the fear is often not the symptom. Someone with a headache may be worried about a tumour; someone with a cough may be worried about their father, who died of lung cancer.
One question - what are you most worried this might be? - surfaces that before the consultation, and consultations that address the worry are the ones patients describe as good. It costs a line on the form and changes the whole encounter.
The cost of asking twice
Chasing details is invisible work: it doesn't appear on any invoice, but it eats the first week of every new relationship. Worse, it happens at exactly the moment a patient is deciding whether you are organised.
This template front-loads it. One link, one pass, everything you need to open the file - and a written record of what they told you.
Paperwork before the appointment, in the patient's own time
Forms filled in at reception are rushed, incomplete and hand-written. The same questions sent with the appointment reminder come back typed, complete and read at home - and you get the first ten minutes of the appointment back.
They also arrive before you need them, so a flagged medication or a mobility need changes the plan in advance rather than in the room.
Nothing to install, nothing to learn
Your patients get a link. No account, no app, no cookie banner between them and the first question. The page is a single file that loads in one request, which on a phone on mobile data is the difference between a submitted form and a closed tab.
Edit it like a document, publish like a link
Add questions, remove questions, change the order and the wording, set your accent colour. When you save, the form is live at its own address - share it by link, QR code or a button on your site, and read the answers in your dashboard.
What this template asks
- Full name
- Date of birth
- Phone number
- What's brought you in?
- How long has it been going on?
- How much is it affecting you?
- Which of these apply?
- What have you already tried?
- What are you most worried this might be?
- Existing medical conditions
- Medication you're taking
- Allergies
- Any of these recently?
- What would you like to get out of today?
- Would you like anyone with you?
More Healthcare forms
Questions
Isn't this the clinician's job to ask?
It is, and they still will - but written first, in the patient's own words, it's more complete and less shaped by what they think you want to hear. Read it before you walk in and the consultation starts further along.
How long should an intake form be?
For a single visit, ten to fifteen questions. Full history belongs in registration, once; intake should be about today.
Can I add or remove questions?
Yes - every question here is a starting point. Add your own, delete what doesn't apply, reorder by dragging, and make anything required or optional. Saving publishes the change immediately.
Where do the answers go?
Into your dashboard, where you can read, filter and export them as a spreadsheet. You can also have every response emailed to you the moment it arrives, or as a daily or weekly digest.
Do I need a website?
No. Every form gets its own link you can paste into an email signature, a text message, a QR code or a social profile. If you do have a site, you can link to it from anywhere on it.
Can I use this for patient information?
Responses are stored in your account, never shared and never used for advertising, and pages are served over encrypted connections. You remain the controller of that data: ask only what you need, say what you keep, and confirm your obligations (HIPAA, UK GDPR or local equivalent) before collecting health information on a web form.
Publish your patient intake form today
Start from this template and change anything you like. Free to begin.