Medical Questionnaire Form
Gather patient contact details and essential medical information effortlessly with this customizable, HIPAA-compliant intake form. This template can be easily tailored to align with your medical institution's unique practice requirements, allowing you to seamlessly integrate it into your existing workflow. Embed the form directly into your website or let patients fill it out on mobile devices before an appointment or procedure. Form responses can appear automatically in your system, filling the corresponding fields of a patient's card, or generating a PDF report.
Structure and logic of the form
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The calendar start view is set up to show the years of the decade. Thus, patients can quickly find their birth year, then select the month and date without endless scrolling through the calendar.
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To make sure patients are over 18 years old, the dates within the last 18 years are disabled. Specify the available date range in the calendar to efficiently schedule appointments, follow-up consultations, or treatment plans, track vaccination expiry dates, and more.
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To simplify the form-filling process and enhance the overall user experience, the age is calculated automatically when the date of birth is entered. The calculation is done using the Moment.js library. Use it to perform various date calculations: find the duration, add or subtract time, and determine the number of business days between two dates.
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The Email field accepts only data matching a specified pattern to ensure valid email entries. Choose from predefined patterns or create custom ones to verify customer information.
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The Phone field accepts only valid phone numbers. You can select which country's formats are accepted in the field properties.
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When patients answer 'yes' to any question, additional fields appear to collect more details. This is done with conditional rules in the Hide property.
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Patients enter their medication list and medical history into the Data Table control. This way, you receive structured and complete data that is easy to analyze. Use tables to monitor vaccination, store and review laboratory test results, and track vital signs like blood pressure and heart rate.
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Patients confirm the accuracy of the data they have provided with a signature.