Patient Intake Questionnaire — shared by the community

Who this template is for

Patient Intake Questionnaire is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.

• Small teams who need a reliable intake process working in healthcare & clinical.
• Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
• Anyone replacing chasing missing details over email with one structured record per enquiry.
• Respondents are the people you send it to — the form asks them 18 questions across 2 screens.
• Mobile-heavy audiences, thanks to the one-question-per-screen card layout.

Why this form is useful

It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.

• 12 questions are required, so submissions arrive complete instead of needing a follow-up email.
• It collects a verified email address so replies and confirmations land.
• It captures a phone number for urgent follow-up.
• It pins the request to a specific date.
• It captures a full postal address.
• Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
• Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
• Every response is stored, searchable and exportable, so nothing depends on one person's inbox.

How to use this template

From copy to live form is a few minutes of work, and every step is reversible.

1. 1Press “Use this template” — a fresh copy of Patient Intake Questionnaire lands in your workspace, ready to edit.
2. 2Rename or delete any question, and change what is required. Nothing here is fixed.
3. 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
4. 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
5. 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.

Logic and conditions blueprint

Exactly how this form behaves as it is answered — 3 conditional rules ship with it.

• Features conditional validation: if “Do you have any allergies?” is Yes, “Allergies and what happens” becomes mandatory before the form can be sent.
• Features conditional validation: if “Are you taking any medication?” is Yes, “Medication and doses” becomes mandatory before the form can be sent.
• Features advanced show logic: if “Is there any chance you are pregnant?” is Yes, the form dynamically exposes “Anything else relevant to this”. Otherwise that question never appears.
• All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.