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Questionnaire template

New Patient Intake

Collects a new patient's details, reason for visit, medical history and lifestyle before the first appointment.

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Healthcare · Patient. All Healthcare templates

Questions in this template

Your Details

  1. Welcome to the practice. Please complete this form before your first appointment so your clinician can prepare. Your information is kept confidential.

  2. What is your full name?

    Open answer

  3. In what year were you born?

    A number from 1910 to 2026

  4. What is your gender?

    Choose one:

    • Female
    • Male
    • Non-binary
    • Prefer not to say

  5. How would you prefer us to contact you?

    Choose one:

    • Phone call
    • Text message
    • Email
    • Post

Reason for Your Visit

  1. What is the main reason you would like to see a clinician?

    Open answer

  2. How long have you had this problem?

    Choose one:

    • Less than a week
    • 1-4 weeks
    • 1-6 months
    • More than 6 months
    • Not applicable, this is a routine check

  3. How much pain are you in right now?

    A number from 0 to 10

Medical History

  1. Has a doctor ever diagnosed you with any of the following? Select all that apply.

    Choose any that apply:

    • Asthma or another lung condition
    • Diabetes
    • Heart disease
    • High blood pressure
    • A mental health condition
    • Other
    • None of these

  2. Which other condition or conditions have you been diagnosed with?

    Condition: Only when Other was selected

    Open answer

  3. Do you take any medicines regularly, including ones bought without a prescription?

    Choose one:

    • Yes
    • No

  4. Please list each medicine and how much you take.

    Condition: Only for patients taking regular medicines

    Open answer

  5. Do you have any allergies, for example to medicines, foods or latex?

    Choose one:

    • Yes
    • No
    • Not sure

  6. What are you allergic to, and what reaction do you get?

    Condition: Only for patients with allergies

    Open answer

  7. Have you ever had an operation or stayed in hospital overnight?

    Choose one:

    • Yes
    • No

Lifestyle

  1. Which best describes your smoking?

    Choose one:

    • I have never smoked
    • I used to smoke
    • I smoke now
    • I only use e-cigarettes

  2. How often do you drink alcohol?

    Choose one:

    • Never
    • Monthly or less
    • Weekly
    • Several times a week
    • Daily

  3. On how many days in a typical week are you physically active for at least 30 minutes?

    A number from 0 to 7