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Patient Intake Forms Survey: Clarity, Duplication, Effort

Evaluate healthcare patient intake forms for clarity, duplication, and effort. Compare digital vs paper to reduce burden and improve experience. Start now.

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

Sample Survey Items

Q1
Multiple Choice
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)
Q2
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
Q3
Numeric
About how many minutes (whole number) did you spend completing intake for that visit?
Accepts a numeric value
Whole numbers only
Q4
Multiple Choice
Attention check: To confirm attention, please select “I am paying attention.”
  • I am paying attention
  • I am not paying attention
Q5
Matrix
During intake, how often did you have to provide the same information more than once?
RowsNever duplicatedRarely duplicatedSometimes duplicatedOften duplicatedNot applicable
Personal details (name, DOB)•••••
Insurance information•••••
Current medications•••••
Allergies•••••
Medical history•••••
Emergency contact•••••
Signatures/consents•••••
Q6
Opinion Scale
Overall, how clear were the intake questions and instructions?
Range: 1 – 10
Min: Very unclearMid: NeutralMax: Very clear
Q7
Long Text
Which specific questions or sections were confusing or unclear? Please be as specific as you can.
Max 600 chars
Q8
Multiple Choice
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)
Q9
Multiple Choice
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
Q10
Ranking
Rank your preferred ways to complete intake for future visits (top = most preferred).
Drag to order (top = most important)
  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
Q11
Rating
For you, how does paper intake compare to digital?
Scale: 10 (star)
Min: Paper is much easier than digitalMax: Paper is much harder than digital
Q12
Constant Sum
If you’ve used digital intake, allocate 100 points to show which parts felt most burdensome (enter 0 for items you didn’t do).
Total must equal 100
  • 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
  • Other
Min per option: 0Whole numbers only
Q13
Multiple Choice
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
Q14
Short Text
What one change would make intake easier next time?
Max 100 chars
Q15
Dropdown
What is your age group?
  • 18–24
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65–74
  • 75+
  • Prefer not to say
Q16
Multiple Choice
How do you describe your gender?
  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q17
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
Q18
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
Q19
Dropdown
Where do you live?
  • North America
  • Europe
  • Latin America/Caribbean
  • Asia
  • Africa
  • Middle East
  • Oceania
  • Prefer not to say
Q20
Multiple Choice
Which device do you usually use to complete digital medical forms?
  • Smartphone
  • Tablet
  • Laptop/desktop
  • Other
Q21
Multiple Choice
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
Q22
Chat Message
Welcome! This brief survey asks about your most recent healthcare intake experience. There are no right or wrong answers.
Q23
Long Text
Any other comments about intake forms or check-in?
Max 600 chars
Q24
AI Interview
AI Interview: 2 Follow-up Questions on Your Intake Experience
AI InterviewLength: 2Personality: Expert InterviewerMode: Fast
Q25
Chat Message
Thanks for completing the survey! Your feedback helps improve patient intake.

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