Evaluates the clarity, duplication, and effort associated with healthcare patient intake forms across digital and paper modalities. Designed for healthcare administrators seeking actionable insights to reduce patient burden and improve the check-in experience.
What's Included
AI-Powered Questions
Intelligent follow-up questions based on responses
Automated Analysis
Real-time sentiment and insight detection
Smart Distribution
Target the right audience automatically
Detailed Reports
Comprehensive insights and recommendations
Template Overview
24
Questions
AI-Powered
Smart Analysis
Ready-to-Use
Launch in Minutes
This professionally designed survey template helps you gather valuable insights with intelligent question flow and automated analysis.
Sample Survey Items
Q1
Chat Message
Welcome! This survey asks about your most recent healthcare intake (check-in) experience. It should take about 5–7 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.
Q2
Multiple Choice
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)
Q3
Multiple Choice
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)
Q4
Dropdown
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
Q5
Opinion Scale
Overall, how clear were the intake questions and instructions?
Range: 1 – 7
Min: Very unclearMid: NeutralMax: Very clear
Q6
Opinion Scale
During intake, how often did you have to provide the same information more than once?
Range: 1 – 5
Min: NeverMid: NeutralMax: Very often
Q7
Multiple Choice
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)
Q8
Multiple Choice
Which of the following issues, if any, made intake harder? Select all that apply.
If any part of the intake was unclear or confusing, please describe it here.
Max chars
Q10
Opinion Scale
Thinking about your overall experience, which format do you prefer for completing intake forms?
Range: 1 – 7
Min: Strongly prefer paperMid: NeutralMax: Strongly prefer digital
Q11
Ranking
Rank your preferred ways to complete intake for future visits (top = most preferred).
Drag to order (top = most important)
On my own device before the visit
On paper at the clinic
On a tablet/kiosk at the clinic
By phone with staff
Q12
Ranking
If you have used digital intake, rank the following steps from most to least burdensome. Include only steps you have experienced.
Drag to order (top = most important)
Creating an account
Logging in or password reset
Insurance card/ID upload or photos
Entering medications
Entering medical history
Reading/signing consents
Payment or billing info
Q13
Multiple Choice
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
Q14
Long Text
What one change would make intake easier for you next time?
Max chars
Q15
AI Interview
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.
AI InterviewLength: 2Personality: [Object Object]Mode: Fast
Reference questions: 4
Q16
Long Text
Based on your responses in this survey, please share any additional thoughts or feelings about the patient intake process.
Max chars
Q17
Dropdown
What is your age group?
18–24
25–34
35–44
45–54
55–64
65–74
75+
Prefer not to say
Q18
Multiple Choice
How do you describe your gender?
Woman
Man
Non-binary
Prefer not to say
Q19
Multiple Choice
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
Q20
Multiple Choice
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
Q21
Dropdown
In which region do you currently live?
North America
Europe
Latin America / Caribbean
Asia
Africa
Middle East
Oceania
Prefer not to say
Q22
Multiple Choice
Which device do you usually use to complete digital medical forms?
Smartphone
Tablet
Laptop / desktop
I don't use digital forms
Other (please specify)
Q23
Multiple Choice
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
Q24
Chat Message
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.
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