When was the visit you’re 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)
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
About how many minutes (whole number) did you spend completing intake for that visit?
Attention check: To confirm attention, please select “I am paying attention.”
- I am paying attention
- I am not paying attention
During intake, how often did you have to provide the same information more than once?
Overall, how clear were the intake questions and instructions?
Which specific questions or sections were confusing or unclear? Please be as specific as you can.
Max 600 chars
Did you need help to complete intake?
- 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)
Which issues made intake harder during your most recent experience? Select all that apply.
- Small text or poor contrast
- Medical jargon or unclear terms
- Too many repeated questions
- Trouble uploading photos/documents
- Login or portal problems
- Accessibility incompatibility (e.g., screen reader)
- Language or translation issues
- Privacy or security concerns
- None of the above
Rank your preferred ways to complete intake for future visits (top = most preferred).
For you, how does paper intake compare to digital?
If you’ve used digital intake, allocate 100 points to show which parts felt most burdensome (enter 0 for items you didn’t do).
Do you feel you are asked to sign the same consent forms too often?
- Yes, too often
- It’s about right
- Too infrequent
- Not sure
What one change would make intake easier next time?
Max 100 chars
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer not to say
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 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
Which device do you usually use to complete digital medical forms?
- Smartphone
- Tablet
- Laptop/desktop
- Other
Do you use any accessibility tools when filling forms? Select all that apply.
- Screen reader
- Zoom/magnification
- Voice input
- Switch or alternative input device
- None of the above
Welcome! This brief survey asks about your most recent healthcare intake experience. There are no right or wrong answers.
Any other comments about intake forms or check-in?
Max 600 chars
AI Interview: 2 Follow-up Questions on Your Intake Experience
Thanks for completing the survey! Your feedback helps improve patient intake.