Healthcare and wellness

Patient intake

The questions change with the reason for the visit: symptoms for a new problem, a medicine name for a refill. Free to use with FillKite.

Live demo

Patient intake

Fill it in and press the button to see how it behaves. Nothing you type is saved or sent.

What is in this form

Your name (required)
Email (required)
Phone
Date of birth (required)
Reason for your visit (required)
Describe your symptoms (required)
How long have you had them?
Which medicine? (required)
Do you have any allergies? (required)
What are you allergic to? (required)

How the conditional logic works

This form shows or hides fields as people answer, so everyone sees only what matters to them.

“Describe your symptoms” appears only when “Reason for your visit” is “New symptoms”.
“How long have you had them?” appears only when “Reason for your visit” is “New symptoms”.
“Which medicine?” appears only when “Reason for your visit” is “Prescription refill”.
“What are you allergic to?” appears only when “Do you have any allergies?” is “Yes”.

Use it on your site

Install FillKite free from WordPress.org.
Download this form with the button above.
Go to FillKite → Import → From a FillKite file, choose the file and import it.

Questions

About this form

Is the patient intake form free?

Yes. It works with the free FillKite plugin, and you can download it and change it as you like.

Is anything I type saved?

No. This demo runs in test mode: FillKite checks your answers like a real form, but nothing is saved and no email is sent.

How do I use this form on my site?

Install FillKite, download the form with the button on this page, then go to FillKite → Import → From a FillKite file and choose the file. After importing, open it in the builder, change anything you like and add it to a page.

Does this form use conditional logic?

Yes. 4 fields or notices show only when earlier answers call for it. “Describe your symptoms” appears only when “Reason for your visit” is “New symptoms”.

What fields does it have?

It has 10 fields: Your name, Email, Phone, Date of birth, Reason for your visit, Describe your symptoms, How long have you had them?, Which medicine? and more.

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Free on WordPress.org

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