Healthcare & wellbeing
Patient intake
A standard intake form so the appointment can start with the conversation rather than the paperwork. Check it against your own regulator's requirements before using it — this is a starting point, not a compliant document.
- Questions
- 11
- Takes about
- 5.5 min
- Style
- One page
- Scoring
- None
Free, no card. It lands in your workspace as an editable draft.
Worth knowing
- The welcome screen and the intro text above the first question carry example turnaround times, policies and promises. Rewrite them as yours before you publish — they are the part respondents take literally.
- Health data is sensitive in every jurisdiction. Check retention, access and lawful basis before collecting any.
What's in it
Before your appointment
Welcome screen
What you'll need A list of any medication you take, with doses if you know them · Your GP'…
Rich text
About you
Page break
- 1
Full name*
Short text
- 2
Date of birth*
Date
- 3
Phone number
Phone
- 4
Email
Email
- 5
Address
Address
Health
Page break
- 6
What brings you in?*
Long text
- 7
Existing conditions
Long text
- 8
Current medication
Long text
- 9
Allergies
Long text
- 10
Your regular doctor or practice
Short text
Consent
Page break
- 11
Consent to treatment*
Consent
Thank you
Ending
How to use this template
Open it as a draft
Press "Use this template" and it lands in your workspace as an editable form with all 11 questions already in it. No card, and nothing is published until you say so.
Cut what you do not need
Every question you remove is one fewer reason to abandon the form. It takes about 5.5 minutes to fill in as it stands, and that is the number worth protecting.
Add from the question bank
Pick what you are missing from the questions below. Drag any of them in, change the wording, and use conditional logic so people only see the ones that apply to them.
Share it, or put it on your own site
Publish to get a link, or embed it in a page you already have. Answers arrive in your dashboard, and you can send them on to anywhere else with a webhook or an integration.
32 patient intake form questions to choose from
Intake forms are filled in by people who are unwell, often on a phone, sometimes in a waiting room. Length is not a neutral choice: every extra question is answered worse than the one before it.
This collects health data, which is special-category under GDPR. The lawful basis and the retention period are yours to set before the form goes live.
Patient details
- What is your full name?
- What is your date of birth?
- What is your address?
- What is your phone number?
- What is your email address?
- What is your NHS or patient number?
- Who is your GP, and which surgery?
- Which pharmacy do you use?
Why they are here
- What brings you in today?
- When did it start?
- How would you describe it?
- Where exactly is it?
- How severe is it? (0 to 10)
- Is it constant or does it come and go?
- What makes it better or worse?
- Have you had this before?
Medical background
- Do you have any ongoing medical conditions?
- What medication are you currently taking?
- Do you have any allergies? What happens?
- Have you had any surgery?
- Have you been in hospital in the last year?
- Is there any relevant family history?
- Are you pregnant or breastfeeding?
- Do you have any other symptoms?
Consent and practicalities
- Who is your emergency contact and their number?
- Do you need an interpreter? Which language?
- Do you have any accessibility requirements?
- Do you consent to treatment?
- Do you consent to us contacting your GP?
- How would you prefer we contact you?
- May we leave a message if you do not answer?
- Have you read our privacy notice?
Patient Intake form questions, answered
- What should a patient intake form ask?
- Identity, presenting complaint, current medication and allergies. Everything else can usually wait for the consultation, and intake forms get longer every year without getting more useful.
- Is it safe to collect health information in an online form?
- Responses are encrypted in transit and at rest, access is controlled by role, and published forms set no cookies. What makes it lawful is your own basis for processing and a retention policy, which no form can supply for you.
- Can patients complete an intake form before they arrive?
- Yes, and it is the main reason to use one. Send the link with the appointment confirmation so the information is already there when they walk in.
- Can patients save an intake form and come back to it?
- Yes. Save and resume gives them a private link to a part-finished form, which matters when the medication question needs a packet from another room.
- Is this patient intake form template free?
- Yes. Use it, publish it and collect answers on the free plan with no card. Paid plans add things like payments, scheduling, removing our badge and your own domain, but none of them are needed to run this form.
- Do I need an account to use it?
- You need one to edit and publish, because the form has to live somewhere and the answers have to come back to you. Signing up takes about a minute and does not ask for a card. The people filling your form in never need an account.
- Can I change the questions?
- All of them. The template is a starting point, not a fixed form: add, remove, reword and reorder anything, change the look, and use logic so people only see the questions that apply to them.
- Can I put it on my own website?
- Yes. Embed it in a page you already have, or share the link. On a paid plan you can serve it from your own domain so the address says your name rather than ours.
- Where do the answers go?
- Into your dashboard, where you can read, search and export them as CSV. You can also have each response emailed to you, pushed to another tool with a webhook, or sent to a connected integration.
- How long does this form take to fill in?
- About 5.5 minutes as it stands, across 11 questions. Every question you cut brings that down, and shorter forms get finished more often.
Worth reading next
- What the rules actually ask of a small business formMost compliance advice is written for companies with legal departments. Here is the short version for a form that collects names and email addresses.
- The five accessibility fixes that matter most on a formNot a WCAG checklist. The handful of things that decide whether somebody using a screen reader or a keyboard can actually finish.