Pediatric Intake Form — shared by the community
Marta K. shared this 28-question build with 4 conditional rules already wired up. Test it below, then take a copy.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 28 questions, 3 pages, 4 conditional rules.
- Shared by
- Marta K. · Practice manager
- Questions
- 28
- Replies
- 21
- Copies taken
- 882
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Live preview and test console
This is the real form. Answer it to test the flow — nothing is sent or stored.
Page 1 of 3 — Child and family
This template runs as a straight sequence — no branching rules.
Works for you? Take Marta K.'s copy into your own workspace — questions, rules and settings included.
Who this template is for
Pediatric Intake Form 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 28 questions across 3 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.
- 17 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 records a signature you can keep as proof of agreement.
- It pins the request to a specific date.
- It captures a full postal address.
- It allows multiple selections without free text.
- It captures a numeric value you can filter and sort on.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Pediatric Intake Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 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.
- 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.
- 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 — 4 conditional rules ship with it.
- Features conditional validation: if “Has any professional raised a concern about development?” is Yes, “Who raised it, and what was said?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Are immunisations up to date?” is No, “Which ones are outstanding, and why?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Is support already in place at school or nursery?” is Yes, “What support is in place?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Does the child take any medication?” is Yes, “Medication and doses” becomes mandatory before the form can be sent.
- All 4 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
What this form asks
Page 1 — Child and family
- Child's full namerequired
- Child's date of birthrequired
- Parent or carer completing this formrequired
- Relationship to the childrequired
- Contact numberrequired
- Email addressrequired
- Home address
- Who else may bring the child to appointments?
- School or nursery
Page 2 — Birth and development
- Pregnancy and delivery, briefly
- Birth weight in kilograms
- How was the child fed as a baby?required
- Did milestones come at about the expected time?required
- Has any professional raised a concern about development?required
- Who raised it, and what was said?
- Are immunisations up to date?required
- Which ones are outstanding, and why?
- Previous illness, surgery or hospital stays
Page 3 — Now
- What would you like help with?required
- How long has it been going on?required
- What is it affecting?required
- Does the child take any medication?required
- Medication and doses
- Allergies and what happens on exposure
- Is support already in place at school or nursery?required
- What support is in place?
- Consentrequired
- Signaturerequired
Conditional logic in this build
- When “Has any professional raised a concern about development?” is Yes, require “Who raised it, and what was said?”.
- When “Are immunisations up to date?” is No, require “Which ones are outstanding, and why?”.
- When “Is support already in place at school or nursery?” is Yes, require “What support is in place?”.
- When “Does the child take any medication?” is Yes, require “Medication and doses”.
Questions about this shared form
Who should complete this form?
An adult with parental responsibility, because the last page records their consent. Where another adult brings the child, name them in the attendance question instead.
Is it suitable for teenagers?
Older children may want to answer for themselves, and many services take a separate account from the young person. Use the Patient Intake Questionnaire alongside it in that case.
Why ask about school support?
Because it tells you what has already been tried and who else is involved, which changes both the assessment and who should receive a copy of any plan.
Does it assess development?
No. It records what the parent reports and what other professionals have said. Any developmental assessment is a clinical activity, not a form output.
Is the Pediatric Intake Form template free to use?
Yes. You can preview and test Pediatric Intake Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Pediatric Intake Form template ask for?
It asks 28 questions across 3 pages, 17 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Pediatric Intake Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
4 conditional rules ship with the template: Features conditional validation: if “Has any professional raised a concern about development?” is Yes, “Who raised it, and what was said?” becomes mandatory before the form can be sent. Features conditional validation: if “Are immunisations up to date?” is No, “Which ones are outstanding, and why?” becomes mandatory before the form can be sent. Features conditional validation: if “Is support already in place at school or nursery?” is Yes, “What support is in place?” becomes mandatory before the form can be sent. All rules are editable in the Logic tab.
Where do responses to the Pediatric Intake Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Pediatric Intake Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
Is the signature on this form legally usable?
The template captures a drawn signature and stores it with the submission, along with the timestamp, so you keep evidence of who agreed and when. Whether that is sufficient depends on your jurisdiction and the agreement itself.
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