Patient Intake Questionnaire
Pre-appointment intake in two parts: contact and cover details, then reason for attending, current medication, allergies and relevant history.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 18 questions, 2 pages, 3 conditional rules.
- Questions
- 18
- Pages
- 2
- Layouts
- classic · card
- Time to complete
- ≈ 6 min
- Conditional rules
- 3
Searches this template answers
- patient intake form
- patient intake questionnaire template
- new patient intake form online
- medical intake form
- clinic intake form
- patient information form
Also filed under
Live preview and test console
This is the real form. Answer it to test the 1 conditional rule — nothing is sent or stored.
Page 1 of 2 — About you
Every question on this page is currently visible.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
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.
- 1Press “Use this template” — a fresh copy of Patient Intake Questionnaire 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 — 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.
About this template
An intake questionnaire exists so the first minutes of an appointment are spent on the problem rather than on transcription. This two-page version splits admin from clinical content. The first page covers who the patient is, how to reach them, who to contact in an emergency and how the visit is being funded, because payment questions asked halfway through clinical detail make people abandon the form. The second page opens with the patient's own account of why they are attending and how long it has been going on, then works through current medication and doses, allergies and what happens on exposure, and past treatment or surgery relevant to the reason for attending. Pregnancy and smoking questions are included because they change management in many settings, and both are easier to answer in private than across a desk. Every clinical field is written as a question a patient can answer without guessing at terminology. The form records nothing beyond what the patient reports, and the clinician remains the person who interprets it.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
Page 1 — About you
- Full namerequired
- Date of birthrequired
- Contact numberrequired
- Email addressrequired
- Home address
- Emergency contact name and numberrequired
- How is this visit being paid for?required
- Insurer or scheme name
Page 2 — Your health
- What would you like help with?required
- How long has this been going on?required
- Are you taking any medication?required
- Medication and doses
- Do you have any allergies?required
- Allergies and what happens
- Past treatment or surgery relevant to this
- Do you smoke or vape?required
- Is there any chance you are pregnant?required
- Anything else relevant to this
18 questions in total.
Example of a completed patient intake questionnaire
A sample intake showing how a patient describes their reason for attending ahead of an appointment.
- Full name
- Nadia Farouk
- Date of birth
- 17/07/1991
- Contact number
- 555-662-9013
- Emergency contact name and number
- Samir Farouk, 555-662-9020
- What would you like help with?
- Recurring headaches over the last month, mostly in the afternoon
- How long has this been going on?
- About four weeks
- Are you taking any medication?
- Yes
- Medication and doses
- Loratadine 10mg, once daily
- Do you have any allergies?
- No
Sample data — no real people, addresses or records are shown.
How the form changes as it's filled in
This template ships with 3 conditional rules, grouped into 3 behaviours driven by 3 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “Do you have any allergies?”
- Makes answers required
If “Do you have any allergies?” is Yes, “Allergies and what happens” becomes required before the form can be submitted.
Driven by “Are you taking any medication?”
- Makes answers required
If “Are you taking any medication?” is Yes, “Medication and doses” becomes required before the form can be submitted.
Driven by “Is there any chance you are pregnant?”
- Reveals questions
If “Is there any chance you are pregnant?” is Yes, the form reveals “Anything else relevant to this”.
Set it up step by step
- 1
Send it with the confirmation
Attach the link to the appointment confirmation so the answers arrive with time to read them, and set a reminder the day before for anyone who has not submitted.
- 2
Keep admin and clinical apart
Payment questions on the first page and clinical questions on the second is what keeps completion high on a longer form.
- 3
Ask for medication as free text
A dropdown of drug names will always be incomplete; ask patients to copy their labels and let the clinician tidy the list.
- 4
Print or display it in the room
The value is realised only if the clinician can see the intake on screen while the patient is talking.
Mistakes to avoid
- Asking for allergy detail without asking what actually happens on exposure, which is the part that changes management.
- Leading with insurance questions, which reads as billing before care and drives abandonment.
- Collecting intakes that nobody opens until the appointment starts, which recreates the problem the form was built to solve.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
Attach the submission to the patient record, flag allergies and medication for the clinician before the appointment, and follow up anyone whose intake is still outstanding the day before.
Works in both layouts
Forms that overlap this one
These pages cover the same subject ground as the patient intake questionnaire, matched on the words people actually search for.
Patient History Form
clinicclinicalclinicianconsultinghealth
Eye Exam Intake Form
clinicclinicalcontactcurrenthealth
Clinic Appointment Request
appointmentclinicclinicalclinicianhealth
Pediatric Intake Form
clinicclinicalcliniciancurrenthealth
Quick Cancellation Form
appointmentclinicclinicaldetailhealth
Quick Patient Check-In
clinicclinicalclinicianhealthhistory
Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
How is this different from the Patient History Form?
The history form is the long three-page version covering family history, lifestyle and systems review. This intake is focused on the current reason for attending and the details needed to see the patient safely.
Should patients complete it at reception instead?
You can, but the whole benefit is having the answers in advance. A tablet at reception mostly produces short answers written under time pressure.
Is a signature needed?
Not for an intake. Consent to a specific treatment is separate and should be taken with the Consent to Treatment Form after the discussion in the room.
Can it be used for a first telehealth appointment?
Yes. Pair it with the Telehealth Appointment Request so remote patients supply the same clinical detail as those attending in person.
Is the Patient Intake Questionnaire template free to use?
Yes. You can preview and test Patient Intake Questionnaire 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 Patient Intake Questionnaire template ask for?
It asks 18 questions across 2 pages, 12 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 Patient Intake Questionnaire 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?
3 conditional rules ship with the template: 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 rules are editable in the Logic tab.
Where do responses to the Patient Intake Questionnaire 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 Patient Intake Questionnaire 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.
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