Patient Medical Report Form Template
A pre-appointment medical form with health and family history captured as grids rather than pages of repeated questions.
- Free to use and customise
- No code — everything is drag and drop
- Embed anywhere — one snippet, any website
What this template uses
- 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
Asking six yes-or-no questions one after another wastes a page. This template puts them in a grid: the questions run down the side, the answers across the top, and the whole history is one glance.
The family history does the same, with a different sort of answer in each column - age, general health, known problems, and whether the relative is living.
The three steps
- Patient details, height and weight
- Health history and any supporting documents
- Family history and privacy confirmation
Please note: adapt the questions and the privacy wording to your own jurisdiction before using this with patients.
Make it yours
Change any field, formula or colour. Then embed it on your website.
Start free with this template ↗