Health Assessment Form
Pre-visit intake form for new patients.
Free to preview — no account needed. Using it creates your own editable copy.
Try the template
These are the real questions. Nothing you answer here is saved or submitted.
Full name*
About this template
Health Assessment Form is a ready-to-use form template with 7 questions that takes about 6 minutes to complete. Pre-visit intake form for new patients.
Healthcare templates cover patient satisfaction, discharge follow-up, telemedicine and pharmacy experience. They are deliberately short: a patient completing a survey is often unwell, tired, or waiting for someone else. Keep clinical detail out of the questionnaire and collect only what you will act on — anything identifying belongs in your clinical system, not in a feedback form. Everything in this template is editable — treat the questions below as a starting point that already has the structure right, then cut what does not apply to you.
- Who should use it
- Hospitals, clinics, diagnostic centres, pharmacies and telemedicine providers.
- When to use it
- After discharge, after a consultation, or as a periodic check on a service line.
What this template helps you measure
- Respondent name
- Preferred dates and scheduling
- Timing and scheduling preferences
- Preferences across a fixed set of options
- Open-ended feedback in respondents’ own words
Every question in this template
7 questions, with what each one is doing there. Change or remove any of them after you make your copy.
Full name*
Short textWhy this matters: Captures who is answering in one short line — long enough to be useful, short enough to scan a hundred of them in a spreadsheet.
Date of birth*
DateWhy this matters: Makes the timing part of the record, which is what lets you spot the weeks that are already full.
Gender*
Single choice- Male
- Female
- Other
- Prefer not to say
Why this matters: Countable by design — this is the question that produces a chart rather than a reading exercise.
Reason for visit
Long textWhy this matters: An open field is what separates two submissions that look identical in every other row.
Current medications
Long textWhy this matters: Deliberately not a dropdown: the honest answer here varies too much between people to survive being turned into a list.
Allergies
Long textWhy this matters: Optional detail is better collected here than chased over email afterwards, when half the people never reply.
Medical history
Long textWhy this matters: A free-text box for the part of the submission your fixed fields cannot hold — usually the part you actually read before deciding.
How to use this template
- 1
Start with the template
Click "Use this template" and SurveyKar creates your own copy of Health Assessment Form, with every question already in place. The original template stays untouched.
- 2
Customise the questions
Reword anything that does not match your business, delete what you do not need, change a question type, or add your own. Shorter forms finish more often — cut before you add.
- 3
Add your branding
Set your logo, brand colours, fonts and background so the page looks like it belongs to you rather than to a survey tool.
- 4
Share it
Publish, then share the link, print the QR code, embed it on your site, or send it to a contact list over email or WhatsApp.
- 5
Read the responses
Results land in your dashboard as they arrive, with charts per question, filters, sentiment analysis on open text, and CSV or PDF export.
What you can customise
Your copy is yours. Nothing in the template is locked, and the original is never changed by anything you do.
Questions and wording
Edit, reorder, delete or add questions. Nothing in the template is locked.
Question types
Swap a rating for NPS, a single choice for a matrix, or add ranking, sliders and file uploads.
Logo and brand colours
Apply your logo, primary colour, fonts and background image to the respondent page.
Conditional logic
Skip questions or branch to a different page based on an earlier answer. Available on the Basic plan and above.
Thank-you page
Write your own closing message, or redirect respondents to a URL of your choice after submitting.
Sharing and distribution
Share by link or QR code, embed it on your website, or send it out over email and WhatsApp campaigns.
Frequently asked questions
Related templates
All Healthcare templatesHospital Discharge Survey
Inpatient experience post-discharge.
Pharmacy Feedback Survey
Quick CSAT for retail pharmacies.
Mental Health Check-in
Brief well-being check-in for patients or employees.
Telemedicine Visit Feedback
Capture feedback after virtual consultations.
Clinic Feedback Form
Quick post-visit feedback for OPD and clinics.
Patient Satisfaction Survey
Standard HCAHPS-style patient experience survey.
Ready to create your survey?
Start with this ready-to-use template and customise it for your needs. You get your own copy in seconds — the template stays exactly as it is.