Patient Intake Form Usability & Burden Assessment

Welcome! This survey asks about your most recent healthcare intake (check-in) experience. It should take about 11 minutes. Your responses are confidential and will be reported only in aggregate. There are no right or wrong answers—we want your honest opinions. Participation is voluntary, and you may stop at any time.

When was the healthcare visit you are thinking about for this survey?

• In the last 30 days
• 31–90 days ago
• 3–12 months ago
• Over 1 year ago
• I haven't visited yet (answering based on forms I've seen)

Overall, how clear were the intake questions and instructions?

Thinking about your overall experience, which format do you prefer for completing intake forms?

What one change would make intake easier for you next time?

What is your age group?

• 18–24
• 25–34
• 35–44
• 45–54
• 55–64
• 65–74
• 75+
• Prefer not to say

Thank you for completing this survey! Your feedback will help improve the patient intake experience. Your responses are confidential and will be used only for research purposes.

How did you complete intake for that visit? Select all that apply.

• On paper at the clinic
• On a tablet/kiosk at the clinic
• On my own device before the visit
• By phone with staff
• Other (please specify)

During intake, how often did you have to provide the same information more than once?

Rank your preferred ways to complete intake for future visits (top = most preferred).

1. On my own device before the visit
2. On paper at the clinic
3. On a tablet/kiosk at the clinic
4. By phone with staff

We'd like to understand your intake experience in a bit more depth. A short follow-up conversation will ask 1–2 additional questions based on your earlier answers.

How do you describe your gender?

• Woman
• Man
• Non-binary
• Prefer not to say

Approximately how long did you spend completing intake for that visit?

• Less than 5 minutes
• 5–10 minutes
• 11–15 minutes
• 16–20 minutes
• 21–30 minutes
• More than 30 minutes
• I don't remember

Did you need help to complete the intake forms?

• No, I completed it on my own
• Yes—from clinic staff
• Yes—from a family member or friend
• Not applicable (I didn't complete forms)

If you have used digital intake, rank the following steps from most to least burdensome. Include only steps you have experienced.

1. Creating an account
2. Logging in or password reset
3. Insurance card/ID upload or photos
4. Entering medications
5. Entering medical history
6. Reading/signing consents
7. Payment or billing info

Based on your responses in this survey, please share any additional thoughts or feelings about the patient intake process.

What is the highest level of education you have completed?

• Less than high school
• High school or equivalent
• Some college / Associate degree
• Bachelor's degree
• Graduate or professional degree
• Prefer not to say

Which of the following issues, if any, made intake harder? Select all that apply.

• Small text or poor contrast
• Medical jargon or unclear terms
• Too many repeated questions
• Trouble uploading photos or documents
• Login or portal problems
• Accessibility incompatibility (e.g., screen reader)
• Language or translation issues
• Privacy or security concerns
• None of the above

How would you describe the frequency with which you are asked to sign consent forms?

• Far too often
• Somewhat too often
• About right
• Not sure
• Not applicable

Which best describes your current employment status?

• Employed full-time
• Employed part-time
• Self-employed
• Unemployed and looking for work
• Not working by choice (e.g., student, caregiver, retired)
• Unable to work
• Prefer not to say

If any part of the intake was unclear or confusing, please describe it here.

In which region do you currently live?

• North America
• Europe
• Latin America / Caribbean
• Asia
• Africa
• Middle East
• Oceania
• Prefer not to say

Which device do you usually use to complete digital medical forms?

• Smartphone
• Tablet
• Laptop / desktop
• I don't use digital forms
• Other (please specify)

Do you use any accessibility tools when filling out forms? Select all that apply.

• Screen reader
• Zoom / magnification
• Voice input
• Switch or alternative input device
• None of the above