Q01
Message
All templates
New Patient Veterinary Intake & Health History Survey
Captures a pet's health history, current symptoms, behavior, and vaccination status before a veterinary visit, for clinics streamlining new or returning patient check-ins. The AI follow-up interview reconstructs the timeline and details of the pet's main symptom so staff arrive at the exam room already briefed.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
Q02
Multiple ChoiceRequired
What is the primary reason for today's visit?
- Wellness or annual checkup
- New symptom or injury
- Follow-up on an ongoing condition
- Vaccination only
- Surgery or procedure
Q03
DropdownRequired
What type of animal are you bringing in today?
- Dog
- Cat
- Bird
- Rabbit
- Reptile
- Other small mammal
- Other
Q04
NumberRequired
How old is your pet, in years? (Enter 0 if under 1 year old.)
Q05
Multiple Choice
Including today, how many times has your pet seen a veterinarian in the last 12 months?
- This is the first visit
- 1 time
- 2-3 times
- 4 or more times
Q06
Multiple ChoiceRequired
Which of the following currently apply to your pet? Select all that apply.
- Known allergies
- A chronic condition (e.g., diabetes, arthritis)
- Currently on medication or supplements
- Recent surgery or injury
Q07
Long Text
List any current medications, supplements, or known allergies, including dosage if known. Leave blank if none.
Q08
Slider MatrixRequired
Compared to normal, how has your pet been doing in the past week?
4 rows, one slider each
- Appetite
- Energy level
- Water intake
- Bathroom habits (frequency or consistency)
Slider 0–10Min:Much lower/worse than usualMax:Much higher/better than usual
Q09
Multiple Choice
How does your pet typically react to veterinary visits?
- Calm and relaxed
- Mildly anxious
- Very anxious or fearful
- Aggressive or defensive
- Varies a lot depending on the visit
Q10
Multiple ChoiceRequired
Is your pet up to date on core vaccinations?
- Yes, up to date
- No, overdue
- Not sure
- Not applicable (e.g., indoor only)
Q11
AI Interview
If the respondent flagged a new symptom, injury, or ongoing condition, reconstruct the full picture: when it started, how it has changed, what triggers or worsens it, and anything the owner has already tried at home. Anchor on specific behaviors and timing rather than general impressions, and if the visit is wellness-only, instead ask what (if anything) has changed about the pet's routine, diet, or behavior since the last visit.
Q12
Multiple Choice
How would you describe your experience as a pet owner?
- First-time pet owner
- Experienced with this type of pet
- Professional or breeder background
- Prefer not to say
Q13
Message
Thank you for sharing this information! Your responses will be added to your pet's chart so the veterinary team can prepare before your appointment.
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.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Includes an AI follow-up interview that reconstructs the timeline and details of the pet's main symptom, so staff walk into the exam room already briefed instead of re-asking basics
- Combines structured intake fields (animal type, age, vet visit history, current conditions, medications/allergies, vaccination status) with a slider matrix tracking recent changes in the pet's condition, giving both hard data and a symptom trendline
- Captures owner context (visit reason, pet's typical reaction to vet visits, owner experience level) alongside clinical history, helping staff tailor handling for anxious animals or first-time owners
- Free tier plus a transparent $50/mo Business plan for clinics that want the adaptive interview and auto-generated pre-visit reports, with no opaque enterprise-only pricing
SurveySparrow
Veterinary Patient History Form TemplateA conversational-style, fielding-ready form for capturing a pet's basic history ahead of a visit. It's built on SurveySparrow's chat-like form UI, which is friendlier than a flat paper form but still a fixed question set. No mechanism to dynamically dig into a specific presenting symptom.
What it does well
- Conversational one-question-at-a-time format that feels less clinical than a paper intake sheet
- Ready to deploy as-is for basic patient history collection
- Backed by a broader survey platform with reporting/dashboard features
Where it falls short
- Static question flow with no adaptive follow-up to probe a flagged symptom's timeline or severity
- No automated quality scoring of open-text responses before staff review
- No published methodology on how any AI-assisted features (if present) generate or score content
Jotform
Veterinary Emergency Intake Form TemplateA drag-and-drop form template focused on emergency intake rather than routine new-patient history, useful for clinics needing fast triage paperwork. It's a static field set that owners fill out once, with no interview logic to reconstruct symptom history. Strong for form customization but not designed for pre-visit clinical briefing.
What it does well
- Highly customizable form builder with widgets, e-signatures, and conditional logic for basic branching
- Purpose-built for emergency/urgent scenarios, which may better fit walk-in clinics
- Large template library so it can be adapted for many intake variants
Where it falls short
- No adaptive AI interview to reconstruct a symptom's onset, progression, or severity in the owner's own words
- No per-response quality scoring, so incomplete or vague answers pass through unflagged
- No auto-generated clinical summary/report for staff before the exam
Typeform
Veterinary Intake Form TemplateA polished, conversational one-question-at-a-time intake form, consistent with Typeform's design-forward style. It collects standard pet and owner details but follows a fixed script for every respondent. There's no capability to branch into a deeper, personalized interview about a specific symptom.
What it does well
- Clean, mobile-friendly conversational UI that likely improves completion rates
- Simple logic jumps for basic conditional branching between questions
- Easy embedding on clinic websites or booking confirmation emails
Where it falls short
- No adaptive AI follow-up interview to reconstruct symptom timelines beyond pre-set branching
- No automated scoring of response quality or completeness for staff triage
- No transparent prompt/methodology disclosure since there's no AI interview component
SurveyMonkey
Veterinarian Patient Intake TemplateA short-form static survey covering essential new-patient intake fields, explicitly positioned as an abbreviated version for quick collection. It suits clinics wanting a fast, low-friction form rather than deep symptom exploration. Reporting is standard survey analytics, not a clinical pre-visit summary.
What it does well
- Deliberately short format reduces owner drop-off and speeds up front-desk processing
- Backed by SurveyMonkey's established survey analytics and export tools
- Simple to customize field-by-field for a specific clinic's intake needs
Where it falls short
- No adaptive AI interview so the 'short form' can't expand into detail only when a symptom is flagged
- No automated per-response quality scoring to flag vague or incomplete symptom descriptions
- No auto-generated exam-ready report; results require manual review in survey dashboard
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.