medical intake Templates

Jump-start your forms with our professionally designed templates.

Full Name

Date of Birth

Position/Job Title

+13 more fields

Workplace Ergonomics Assessment Intake Form

Medical Intake

Collect information to assess ergonomic needs and workplace adjustments for employees.

Work Environment Allergy Checklist

Medical Intake

Identify any allergies or sensitivities that employees may have related to the work environment.

Travel and Relocation Health Assessment Form

Medical Intake

Assess the health of employees before travel or relocation for work purposes.

I understand the benefits and risks of telemedicine, and I agree to participate in telemedicine services.

Full Name

+3 more fields

Telemedicine Consent Form

Medical Intake

Capture patient consent for telemedicine services.

Rehabilitation Progress Form

Medical Intake

Track and document the progress of a patient undergoing rehabilitation.

Full Name

Date of Birth

Do you have any allergies to medications?

+4 more fields

Pre-Surgery Assessment Form

Medical Intake

Assess readiness for surgery and collect necessary information.

Pre-Employment Risk Factor Assessment Form

Medical Intake

Assess potential health risk factors for new employees before employment.

Pre-Employment Health Questionnaire

Medical Intake

Collect relevant health information from potential employees before employment.

Child's Full Name

Date of Birth

Parent/Guardian Full Name

+7 more fields

Pediatric Patient Information Form

Medical Intake

Perfect for pediatricians to collect patient information.

Patient Satisfaction Survey

Medical Intake

Capture patient feedback with a professional survey.

Patient Demographics Form

Medical Intake

Capture patient demographic information such as name, date of birth, gender, ethnicity, race, marital status, primary language, and signature.

Immunization Record for Occupational Health

Medical Intake

Collect immunization records from employees for occupational health purposes.

New Patient Registration

Medical Intake

Allow patients to easily register as new patients.

Mental Health and Stress Level Assessment Form

Medical Intake

Evaluate the mental health and stress levels of employees for workplace support and well-being.

Medication Refill Request

Medical Intake

Allow patients to request medication refills easily.

Full Name

Date of Birth

Primary Care Physician

+11 more fields

Medical History Form

Medical Intake

Patient medical and health history form.

Insurance Provider

Insurance Policy Number

Group Number

+5 more fields

Insurance Information Form

Medical Intake

Allow patients to easily provide their insurance information.

I have read and understand the Notice of Privacy Practices.

I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations.

+4 more fields

HIPAA Privacy Acknowledgment

Medical Intake

Capture patient acknowledgment of HIPAA privacy practices.

Diabetes Monitoring Form

Medical Intake

Track important health data for effective diabetes management.

Follow-Up Visit Information

Medical Intake

Securely collect follow-up visit information with this professional form.

Employee Full Name

Date of Birth

Date of Original Exposure

+11 more fields

Follow-Up Visit for Occupational Exposure Form

Medical Intake

Document follow-up visits for employees who have experienced occupational exposure.

Comprehensive Health History and Current Health Status Form

Medical Intake

Capture a detailed health history and current health status for new employees.

Full Name

Date of Birth

+8 more fields

Doctor’s Appointment Request Form

Medical Intake

Submit a request for scheduling a doctor’s appointment.

Have you experienced any of the following symptoms in the past 14 days?

Have you been in contact with anyone diagnosed with COVID-19 in the past 14 days?

Have you traveled internationally in the last 14 days?

+4 more fields

COVID-19 Screening Form

Medical Intake

COVID-19 screening form for healthcare providers.

Full Name of Employee

Date of Birth

Position/Job Title

+8 more fields

Consent for Medical Examination Form for Employee

Medical Intake

Collect consent from employees before a medical examination for occupational purposes.

I have read and understand the treatment description.

Full Name

+3 more fields

Consent for Treatment

Medical Intake

Capture patient consent for treatment with a professional form.

Full Name

Date of Birth

Have you ever been diagnosed with a mental health condition?

+5 more fields

Behavioral Health Intake Form

Medical Intake

Capture patient information for behavioral health assessment.

Location of Pain

Pain Intensity (0-10)

Pain Duration

+4 more fields

Pain Assessment Form

Medical Intake

Assess pain levels and symptoms for patients.

Formisoft

Workplace Ergonomics Assessment Intake Form

Work Environment Allergy Checklist

Travel and Relocation Health Assessment Form

Telemedicine Consent Form

Rehabilitation Progress Form

Pre-Surgery Assessment Form

Pre-Employment Risk Factor Assessment Form

Pre-Employment Health Questionnaire

Pediatric Patient Information Form

Patient Satisfaction Survey

Patient Demographics Form

Immunization Record for Occupational Health

New Patient Registration

Mental Health and Stress Level Assessment Form

Medication Refill Request

Medical History Form

Insurance Information Form

HIPAA Privacy Acknowledgment

Diabetes Monitoring Form

Follow-Up Visit Information

Follow-Up Visit for Occupational Exposure Form

Comprehensive Health History and Current Health Status Form

Doctor’s Appointment Request Form

COVID-19 Screening Form

Consent for Medical Examination Form for Employee

Consent for Treatment

Behavioral Health Intake Form

Pain Assessment Form