Ready-to-Use Template

Healthcare Intake Form

Collect patient information and medical history for healthcare intake, including contact details, symptoms, and important health details.

The Healthcare Intake Form helps clinics and healthcare providers collect patient information online using Contact Form 7. It has a simple layout that is easy to set up and allows patients to share their details before visiting the clinic instead of completing paper forms. In this template, you’ll find fields to collect personal details such as name, address, contact information, and date of birth. It also includes sections for medical history, current health concerns, allergies, medications, and emergency contact details. These fields help healthcare teams get a better understanding of a patient’s background before the appointment. Overall, this form provides a convenient way to manage patient intake information through your website. It helps you organize important health details in one place and makes appointment preparation easier for clinics and patients.

Healthcare Intake Form

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First Name *

Last Name *

Patient Age * Prefered Name / Nickname * Patient Gender * Phone Number * Spouce Name With whome do you live? Marital Status * Marital status(other) Occupation Retired? *

Date of retirement

Disability ? * Who is your primary care doctor: Where is your primary care doctor located ? Phone Number of primary care doctor: Allergic to any medications Allergic to any medications Do you smoke?

How many years did you smoke?

If you quit, when did you stop? Do you drink alcohol? Personal opinion


    
    <label> First Name *
        [text* your-first-name autocomplete:first-name] </label>
    
    
    <label> Last Name *
        [text* your-last-name autocomplete:last-name] </label>
    


<label> Patient Age *
    [number* patient-age] </label>

<label> Prefered Name / Nickname *
    [text* patient-name] </label>

<label> Patient Gender *
    [select* patient-gender first_as_label "-select-" "Male" "Female" "Shemale"] </label>

<label> Phone Number *
    [phone* phone validation:1] </label>

<label> Spouce Name
    [text spouce-name] </label>

<label> With whome do you live?
    [text live] </label>

<label> Marital Status *
    [select* marital-status first_as_label "-select-" "Married" "Unmarried" "other"]</label>

<label> Marital status(other)
    [text marital-status-other]</label>

<label> Occupation
    [text occupation]</label>

<label> Retired? *
    [select* retired first_as_label "-select-" "Yes" "No"]</label>


<label> Date of retirement
    [date_time date_time-743 "m/d/Y"]</label>


<label> Disability ? *
    [select* disability first_as_label "-select-" "Yes" "No"]</label>

<label> Who is your primary care doctor: 
    [text primary-care-doctor]</label>

<label> Where is your primary care doctor located ?
    [text primary-care-doctor-located]</label>

<label> Phone Number of primary care doctor:
    [phone* care-doctor-phone validation:1]</label>

<label> Allergic to any medications
    [select allergic first_as_label "-select-" "Yes" "No"]</label>

<label> Allergic to any medications
    [text allergic-medications]</label>

<label> Do you smoke? 
    [select smoke first_as_label "-select-" "Yes" "No"]</label>


    <label> How many years did you smoke?
        [number smoke-year]</label>


<label> If you quit, when did you stop?
    [text smoke-stop]</label>

<label> Do you drink alcohol? 
    [text drink-alcohol]</label>

<label> Personal opinion
    [textarea personal-opinion x3]</label>

[submit "Submit"]

Input Fields Used in this Template

Explore the advanced functionalities that extend Contact Form 7, enhancing your form capabilities and optimizing user interactions

Text Field

Number field

Dropdown select

Phone Field

Date Time Field

Textarea field

Submit button

Here is a user-friendly healthcare intake form collects essential information clearly and efficiently. It helps users easily register for healthcare services.

First Name: The patient’s given name for identification.
Last Name: The patient’s family name for identification.
Patient Age: The patient’s age for medical context and records.
Preferred Name / Nickname: A preferred name the patient likes to be called (optional).
Patient Gender: The patient’s gender selection for health records.
Phone Number: A valid contact number where the patient can be reached if needed.
Spouse Name: Name of the patient’s spouse (optional).
With Whom Do You Live?: The person(s) the patient lives with for social/medical context.
Marital Status: The patient’s marital status (e.g., Married, Unmarried, Other).
Marital Status (Other): If “Other” is selected, specify the marital status.
Occupation: The patient’s current job or occupation (optional).
Retired?: Indicates whether the patient is retired (Yes/No).
Date of Retirement: If retired, the date when retirement occurred (optional).
Disability?: Indicates whether the patient has a disability (Yes/No).
Who is Your Primary Care Doctor: Name of the patient’s primary care doctor (optional).
Where is Your Primary Care Doctor Located?: Location of the primary care doctor (optional).
Phone Number of Primary Care Doctor: Contact number for the primary care doctor (optional).
Allergic to Any Medications?: Indicates whether the patient has known medication allergies (Yes/No).
Allergic to Any Medications (Details): Specify the allergies if applicable.
Do You Smoke?: Indicates whether the patient smokes (Yes/No).
How Many Years Did You Smoke?: Total years the patient smoked (optional).
If You Quit, When Did You Stop?: The date or time when the patient stopped smoking (optional).
Do You Drink Alcohol?: Information about alcohol consumption (open text).
Personal Opinion: A text area for any personal comments or additional health information.
Math Captcha: A simple math challenge to verify human users and prevent spam.
Submit Button: The action button the user presses to send the completed healthcare intake form.

Feature of this Template

Here is a quick overview of the features of this template, highlighting its key functions and how they can help you automate your process.

Personal Information: Collects basic details like name, age, gender, and contact information.
Medical History: Gathers information on past medical conditions, surgeries, or treatments.
Current Health Concerns: Asks about present symptoms or health issues the patient is experiencing.
Medications: Inquires about current medications, dosages, and frequency.
Allergies: Collects information about any known allergies to medications, foods, or environmental factors.
Family Health History: Requests details on hereditary health conditions or diseases in the family.