Medical Intake Form Template
A nine-step patient intake form covering history, vaccinations, allergies, mental health and medication.
- Free to use and customise
- No code — everything is drag and drop
- Embed anywhere — one snippet, any website
What this template uses
- Saves submissions to Google Sheets
- Stores leads and can notify you by email
- Connects to CRMs and supports webhooks
This is the real template — step through it, but submissions are switched off here.
About this template
A full patient history is a long document. This template splits it into nine short steps and puts every repeated question into a grid, so nine conditions take nine lines rather than nine pages.
Patients complete it before the appointment. The clinician arrives with something to read rather than a blank form to work through.
The nine steps
- About you
- Tuberculosis screening
- Vaccinations
- Allergies
- Sexual health
- Medical history, across ten body systems
- Mental health
- Reproductive health
- Dental and medication
Please note: this is a starting point, not clinical guidance. Have your own clinical lead review it before use.
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Make it yours
Change any field, formula or colour. Then embed it on your website.
Start free with this template ↗