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Medical Intake Form

The medical intake form is a critical document that helps the healthcare provider to get a complete picture of the patient's condition. It is used to determine the best course of treatment for the individual. On, you can easily select this medical intake form template and create your custom form in minutes.

Medical Intake Form


What is a medical intake form?

A medical intake form is a document used to collect information about a patient's health history, including current health problems and medications. The form is also used to record the patient's contact information, insurance information, and other relevant data. This online medical history form may be completed by the patient, or a health care provider may collect the information during a medical visit.

The purpose of this type of inquiry form is to provide a comprehensive record of the patient's health history. This information can be used to diagnose and treat current health problems, as well as to identify potential risk factors for future health problems. The medical intake form is an important part of the patient's health record, and it should be updated as needed to reflect any changes in the patient's health status.

What does a typical medical intake form include?

Similar to a patient intake form, a medical intake form is basically a way to collect information. As the nature of their job requires, physicians need every bit of relevant information to make the right decisions. This secure online medical intake form template comes with common form questions and form fields. And here are some of the questions you can ask with an intake form online:

  • Patient forms usually start with questions for collecting personal information, such as name, address, and phone number. Additionally, you can ask them to add an emergency contact, for any unforeseen event.
  • Depending on the age of the individual there may be other sections containing consent for treatment or parental permission for minors.  
  • This document should ask for a list of current symptoms, allergies, and current medications the patient is taking. This may include a description of the problem, as well as when it began and any aggravating or relieving factors.
  • Alongside current illnesses, one can add questions about the individual's medical history, as well. This may include past surgeries, hospitalizations, illnesses, and/or injuries. The questions in this section may also ask about family history of specific medical conditions. 
  • It is also possible to allow your patients to upload some fields. For example, you can ask them to send you diagnostic tests and results. This may include information about blood tests, X-rays, or scans that have been ordered.

By using’s easy and extensive form builder user interface, you can create online forms, surveys, and exams with less effort than anything else! You can quickly start with a ready-made template and customize it according to your needs or you can start from scratch and build your form with many different types of form fields and customization options. 

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Let our templates do errands for you and let you focus more on critical parts of your forms and surveys such as form fields, questions, and design customization. With over 100 templates, enables you to create a form that you need and customize it according to your needs by using our form creator.

You can share your forms in any way you like. If you want to share your form and collect responses through your form’s unique link, you can simply adjust privacy settings and copy paste your form link anywhere. And if you would like to embed your form in your website, you can easily copy and paste embed code in your website HTML.

On, you can customize your form’s theme and design elements in depth. Once you switch to the ‘Design’ tab after getting your form done, you will see many different design customization options. You can change your form theme by choosing your own colors or picking one of many ready-made themes.