Q01
Message
All templatesHealthcare & Clinical
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 · ~11 min
Q02
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)
Q03
Opinion Scale
Overall, how clear were the intake questions and instructions?
Scale: 1 – 7
Min:Very unclearMax:Very clear
Q04
Opinion Scale
Thinking about your overall experience, which format do you prefer for completing intake forms?
Scale: 1 – 7
Min:Strongly prefer paperMax:Strongly prefer digital
Q05
Long Text
What one change would make intake easier for you next time?
Q06
Dropdown
What is your age group?
- 18–24
- 25–34
- 35–44
- 45–54
- 55–64
- 65–74
- 75+
- Prefer not to say
Q07
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.
Q08
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)
Q09
Opinion Scale
During intake, how often did you have to provide the same information more than once?
Scale: 1 – 5
Min:NeverMax:Very often
Q10
Ranking
Rank your preferred ways to complete intake for future visits (top = most preferred).
- On my own device before the visit
- On paper at the clinic
- On a tablet/kiosk at the clinic
- By phone with staff
Drag to rank
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?
- Woman
- Man
- Non-binary
- Prefer not to say
Q13
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
Q14
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)
Q15
Ranking
If you have used digital intake, rank the following steps from most to least burdensome. Include only steps you have experienced.
- 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
Drag to rank
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?
- 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 of the following issues, if any, made intake harder? Select all that apply.
- Small text or poor contrast
- Medical jargon or unclear terms
- Too many repeated questions
- Trouble uploading photos or documents
- Login or portal problems
- Accessibility incompatibility (e.g., screen reader)
- Language or translation issues
- Privacy or security concerns
- None of the above
Q19
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
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
Long Text
If any part of the intake was unclear or confusing, please describe it here.
Q22
Dropdown
In which region do you currently live?
- North America
- Europe
- Latin America / Caribbean
- Asia
- Africa
- Middle East
- Oceania
- Prefer not to say
Q23
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)
Q24
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
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
- Combines structured questions (visit timing, modality used, time spent, clarity and duplication ratings) with an open-text field for describing confusing steps and a ranking exercise for preferred intake methods and most burdensome digital steps
- Includes an AI follow-up interview to probe deeper into a respondent's specific intake pain points beyond what fixed-choice questions can capture
- Captures accessibility tool usage and device type alongside standard demographics, letting healthcare administrators segment burden findings by patient population
- Produces an auto-generated report summarizing clarity, duplication, and preference patterns, rather than leaving analysis to the researcher
SurveySparrow
Free Patient Intake Form Template | For Admitting New PatientsThis is a data-collection form for admitting new patients (name, insurance, medical history, etc.), not a research survey measuring how clear, duplicative, or burdensome the intake process feels. It's fielding-ready as an intake document but serves a different purpose than a usability/burden assessment.
What it does well
- Purpose-built for the actual patient admission workflow
- Likely offers drag-and-drop customization typical of SurveySparrow's builder
- Free to use as a static template
Where it falls short
- No adaptive AI follow-up to probe why a patient found a step confusing
- No mechanism to measure duplication of information requests or comparative burden across digital vs. paper intake
- No published methodology or automated quality scoring of open responses
Jotform
Telemedicine Patient Intake Form TemplateAlso a patient-facing intake form (for telemedicine visits specifically) rather than a survey evaluating the intake experience itself. Useful for collecting pre-visit patient data, but it doesn't ask patients to rate clarity, repetition, or preferred formats.
What it does well
- Tailored to telemedicine-specific intake fields
- Backed by Jotform's widely used form-builder ecosystem with integrations
- Fielding-ready as an actual intake document
Where it falls short
- Not designed to assess burden, clarity, or duplication as research constructs
- No adaptive AI interviewing or voice interview option to explore patient frustration in their own words
- No ranking or comparative preference measurement across intake modalities
Frequently asked questions
What questions are in the “Patient Intake Form Usability & Burden Assessment” template?
The template includes 24 ready-to-use questions, starting with: “Welcome! This survey asks about your most recent healthcare intake (check-in) experience. It should take about 11 minute…” · “When was the healthcare visit you are thinking about for this survey?” · “Overall, how clear were the intake questions and instructions?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 24 questions in about 11 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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