Q01
Message
All templatesHealthcare & Clinical
Pre-Visit Patient Intake & Symptom Screening Survey
Collects chief complaint, symptom severity, medical history, and current medications before an appointment so clinicians walk in prepared. An AI follow-up interview reconstructs the timeline and context behind the patient's main concern — onset, triggers, and what's already been tried — that a checkbox history alone can't capture.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
15 questions · ~8 min
Q02
ConsentRequired
Please review before continuing.
Q03
Short TextRequired
In your own words, what is the main reason for your visit today?
Q04
Multiple ChoiceRequired
How long have you been experiencing this main issue?
- Less than 24 hours
- A few days
- About a week
- Several weeks
- A month or more
- This is an ongoing/chronic issue
Q05
Opinion ScaleRequired
On a scale of 0 to 10, how would you rate your pain or discomfort right now?
Scale: 0 – 10
Min:No painMax:Worst pain imaginable
Q06
MatrixRequired
Over the past week, how severe have the following symptoms been? (Template note: replace this list with the symptom set relevant to your specialty before launching.)
5 rows × 4 columns
- Fatigue
- Fever or chills
- Nausea or vomiting
- Shortness of breath
- Dizziness or lightheadedness
Columns: None · Mild · Moderate · Severe
Q07
Multiple ChoiceRequired
Do you currently have, or have you ever been diagnosed with, any of the following? (Template note: swap in the condition list your practice screens for.)
- Diabetes
- High blood pressure
- Heart disease
- Asthma or lung disease
- Kidney disease
- Cancer (past or present)
- Autoimmune condition
Q08
Long Text
Please list all medications, vitamins, and supplements you currently take, including dose and frequency if known.
Q09
Short TextRequired
Do you have any known allergies (medications, foods, or environmental)? If none, please write 'None.'
Q10
Rating ScaleRequired
How much is this issue interfering with your daily activities (work, sleep, family, etc.)?
Range: 1 – 5
Min:Not at allMax:Completely
Q11
AI Interview
Reconstruct the story behind the patient's main complaint: when it started, how it has changed since then, what makes it better or worse, and what (if anything) they've already tried, including over-the-counter remedies. If they rated their pain or interference high, probe concretely on how it's affecting a specific recent day. If their answers are vague or minimize severity, gently ask for a specific recent example.
Q12
Message
Almost done — just a couple of background questions. These are optional and help us keep accurate records.
Q13
Date
What is your date of birth?
Q14
Multiple Choice
What is your gender identity?
- Male
- Female
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q15
Message
Thank you for sharing this with us. Your responses will be added to your chart and reviewed by your care team before your appointment so we can make the most of your time together.
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
- Goes beyond checkbox history: an AI follow-up interview reconstructs the timeline behind the chief complaint — onset, triggers, and what's already been tried — so clinicians walk in with context, not just a symptom list.
- Combines structured clinical data (symptom severity matrix, pain rating, medication list, allergy check, medical history) with a conversational layer that adapts to each patient's actual answers.
- Uses a consent step and clear chat-style framing to set expectations before collecting sensitive health information, and closes with a message confirming responses will be added to the chart.
- Separates optional demographic questions (date of birth, gender identity) from clinical questions, reducing friction on the medically essential parts of the intake.
Jotform
Medical Patient Intake Form TemplateA standard fielding-ready form for collecting patient demographics, history, and reason for visit. It's built for quick data capture and integrates with Jotform's broader form ecosystem (e-signatures, file uploads), but it is a static questionnaire rather than an interview. Good for basic intake paperwork, less suited to capturing nuance around a patient's symptom story.
What it does well
- Established, widely-used form builder with strong customization and integration options
- Likely supports e-signature and file upload fields useful for intake paperwork
- Simple to deploy and embed on a clinic website or patient portal
Where it falls short
- Static form fields only — no adaptive follow-up questioning to explore onset, triggers, or prior treatment attempts
- No per-response quality scoring or automated report generation for clinicians
- No transparent, published methodology for how questions are structured or scored
Typeform
Appointment Request Form TemplateThis is primarily an appointment-request/scheduling form with intake fields layered in, styled in Typeform's conversational one-question-at-a-time format. It's polished and easy for patients to complete, but it's a fixed script — it doesn't ask context-aware follow-ups. It reads more as a booking + basic-intake hybrid than a deep symptom-screening tool.
What it does well
- Clean, mobile-friendly conversational form design that patients find easy to complete
- Combines appointment scheduling with basic intake in one flow
- Strong brand reputation for form completion rates and UX polish
Where it falls short
- No adaptive AI interviewing — every patient sees the same fixed question sequence regardless of their answers
- No mechanism to reconstruct symptom timeline, triggers, or prior treatments beyond what's explicitly asked
- No automated quality scoring or clinician-facing report generation built for clinical intake
Frequently asked questions
What questions are in the “Pre-Visit Patient Intake & Symptom Screening Survey” template?
The template includes 15 ready-to-use questions, starting with: “Welcome! Before your visit, we'd like to gather some background on how you've been feeling. Your responses are completel…” · “Please review before continuing.” · “In your own words, what is the main reason for your visit today?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 15 questions in about 8 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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