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Patient Intake Form
This template helps healthcare providers collect and maintain a record of patients' personal, medical, and insurance information. This free online patient intake form offers three main benefits for healthcare providers:- Saving time by collecting patient information
- Reducing data entry mistakes
- Keeping a record of the patient’s medical history
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About this digital patient intake form template
A patient intake form is a document used by doctors, nurses, and healthcare providers to gather extensive information about a patient's personal details, medical history, current health concerns, primary care provider information, and insurance details.
Form questions will collect information about:
- Personal information (full name, date of birth, gender, contact details)
- Emergency contact information
- Insurance provider and policy details
- Primary care provider information
- Medical history (past illnesses, surgeries, chronic conditions)
- Current medications and supplements
- Allergies and adverse reactions
- Current symptoms or reason for visit
- Lifestyle factors (smoking, alcohol use, exercise habits)
- Family medical history
- Previous hospitalizations or treatments
- Consent for treatment and privacy agreements
Who uses a patient intake form?
Patient intake forms are primarily used by hospitals, clinics, and private practitioners such as dentists and therapists to get a wide range of patient details and reduce wait times for patients to complete in the waiting room.
Hospitals & clinics
Large hospitals and clinics heavily use online patient intake forms. They use online intake forms not only to register the patients and maintain a record of them, but also to standardize the process professionally.
Private practitioners (doctors, dentists, therapists, etc.)
Smaller practitioners also utilize online patient intake forms to gather information about new patients’ past treatments and complaints, thereby saving time for front desk staff before the visit.
What should I ask in a patient intake form?
The questions to ask in a patient intake form can vary depending on the department of your healthcare provider. However, the questions below will be enough for most providers to get started:
- What is your full name, date of birth, and contact information?
- Who should we contact in case of an emergency, and what is their relationship to you?
- What is the name and contact information of your primary care provider?
- Do you have health insurance? If yes, please provide your provider and policy number.
- Do you have any known allergies (medications, food, or environmental)?
- What medications, vitamins, or supplements are you currently taking?
- Have you had any major surgeries, hospitalizations, or chronic conditions?
- What is your family’s medical history (heart disease, diabetes, cancer, etc.)?
- What symptoms, concerns, or reasons bring you in today?
- Do you consent to treatment and acknowledge our privacy policies?
Frequently asked questions (FAQs)
Is this patient intake form legally binding?
A patient intake form is legally binding only if it includes an electronic signature field and complies with applicable laws. Electronic signatures can be legally binding if they meet certain conditions, such as identifying the signer and proving that they have access to the private key used.
Can I add my own logo to this form?
Yes, it is! You are free to place your logo in any convenient place for free.
Is this patient intake form free?
Yes. This patient intake form is totally free to use, along with other health-related form templates on forms.app.
Can I customize this template based on my own usage?
Yes, this form is fully customizable, meaning that you can change every element of the form through forms.app’s drag-and-drop interface and multiple question types.
Use this online patient intake form template
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Smooth intake process for everyone
Create your patient intake form with powerful features and make the intake process simple and clear for everyone.
Legal fields
Add a signature field so patients can sign the form and provide valid consent.
Open-ended fields
Allow patients to give extra intake details through text, masked, or open fields.
File upload fields
Easily collect necessary medical documents from your patients in any format.
Contact fields
Collect fundamental patient data such as name, email, phone number, and address easily.
Date & time fields
Let patients provide their date of birth, appointment preferences, or last visit dates.
Rating scales
Assess patient complaints, pain levels, symptom severity, and satisfaction with rating scales.