Classic form
Patient intake form
A new patient form that gets the clinical picture and the paperwork done before the appointment starts, in language a patient can answer without a nurse beside them.
The form itself
A static copy of the finished form, exactly as it renders. Nothing here can be filled in or submitted, so read it as a reference and build your own from the button above.
Every field, and what it collects
The complete field list, in the order respondents meet it.
- Full nameNameRequired
- Date of birthDateRequired
- GenderDropdown
- Options: Female · Male · Non-binary · Prefer to self describe · Prefer not to say
- Email addressShort textRequired
- Mobile numberShort textRequired
- Home addressAddress
- Preferred languageShort text
- Tell us if you would like an interpreter and we will arrange one.
- Contact nameShort textRequired
- Relationship to youShort text
- Contact phoneShort textRequired
- What brings you in today?Long textRequired
- How long has this been going on?Short text
- How much is it affecting your day?Dropdown
- Options: Not much · A little · A fair bit · A lot · I cannot do my normal activities
- Have you ever been told you have any of these?Multiple choice
- Options: Asthma · Diabetes · High blood pressure · Heart disease · Stroke · Cancer · Thyroid condition · Depression or anxiety · Epilepsy · Kidney disease · Liver disease · None of these
- Past surgery or hospital staysLong text
- Medicines you take nowTable
- Include anything over the counter, vitamins and supplements.
- Columns: Medicine · Dose · How often
- AllergiesLong textRequired
- Has a parent, brother or sister had any of these?Multiple choice
- Options: Heart disease · Diabetes · Cancer · Stroke · High blood pressure · None of these
- Do you smoke?Single choice
- Options: Never · Used to · Yes, occasionally · Yes, daily
- AlcoholSingle choice
- Options: None · A few drinks a month · A few drinks a week · Most days
- Health fundShort text
- Member numberShort text
- Photo of your cardPhoto upload
- Optional. It saves us typing it in at the front desk.
- ConsentMultiple choiceRequired
- Options: I have received the Notice of Privacy Practices · I consent to assessment and treatment · I accept responsibility for any fees not covered by my fund
- Signed by patient or guardianSignatureRequired
Your details
Emergency contact
Why you are coming in
Medical history
Lifestyle
Insurance and payment
Privacy and consent
What makes this form work
The reason for the visit is asked in the patient's words
"What brings you in today" gets a usable answer. A dropdown of complaints gets the closest wrong one, and the clinician has to start again.
Medications are a table, not a paragraph
Name, dose and frequency in three columns is the shape a clinician reads. A free-text list arrives missing the dose roughly every time.
Consent is three separate lines
Privacy notice, consent to treat, and financial responsibility are three different agreements. Bundling them into one tick is what makes a consent easy to challenge later.
Questions people ask
What has to be on a new patient form?
There is no fixed legal list. In practice: demographics, insurance, current medications, allergies, relevant medical and family history, the reason for the visit, an emergency contact, and consent including a privacy acknowledgment.
Is an online intake form HIPAA compliant?
Compliance depends on your setup, not the form fields. You need a signed business associate agreement with your vendor, encryption, and access controls. Confirm those before you collect health information online.
Why ask for allergies as free text?
Because the reaction matters as much as the substance. "Penicillin, brings on a rash" and "penicillin, anaphylaxis" are the same tick in a checklist and very different in a consulting room.
Build your own in about a minute
The button below opens the form generator with this use case already described. Change the wording to match your own, generate, then edit anything you like.
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