Q01
Long Text
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Patient Intake Form Usability & Burden Assessment
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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
24 questions · ~4 min
Q02
Multiple Choice
When was the healthcare visit you are thinking about for this survey?
Q03
Long Text
Overall, how clear were the intake questions and instructions?
Q04
Long Text
Thinking about your overall experience, which format do you prefer for completing intake forms?
Q05
Long Text
What one change would make intake easier for you next time?
Q06
Long Text
What is your age group?
Q07
Long Text
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.
Q08
Multiple Choice
How did you complete intake for that visit? Select all that apply.
Q09
Long Text
During intake, how often did you have to provide the same information more than once?
Q10
Long Text
Rank your preferred ways to complete intake for future visits (top = most preferred).
Q11
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.
Q12
Multiple Choice
How do you describe your gender?
Q13
Long Text
Approximately how long did you spend completing intake for that visit?
Q14
Multiple Choice
Did you need help to complete the intake forms?
Q15
Long Text
If you have used digital intake, rank the following steps from most to least burdensome. Include only steps you have experienced.
Q16
Long Text
Based on your responses in this survey, please share any additional thoughts or feelings about the patient intake process.
Q17
Multiple Choice
What is the highest level of education you have completed?
Q18
Multiple Choice
Which of the following issues, if any, made intake harder? Select all that apply.
Q19
Multiple Choice
How would you describe the frequency with which you are asked to sign consent forms?
Q20
Multiple Choice
Which best describes your current employment status?
Q21
Long Text
If any part of the intake was unclear or confusing, please describe it here.
Q22
Long Text
In which region do you currently live?
Q23
Multiple Choice
Which device do you usually use to complete digital medical forms?
Q24
Multiple Choice
Do you use any accessibility tools when filling out forms? Select all that apply.
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.