Intake forms: what to include, with examples

An intake form is a questionnaire a health practice uses to gather information before an appointment or first service. Practices also call intake forms new patient forms, client intake forms, patient intake forms or registration forms, depending on what the documents collect.

Intake form questions should ask for one fact at a time and use wording patients can answer without clinical training. The following generic questions show how a practice manager can phrase fourteen fields across registration, history, consent and policy sections.

• Contact details: “What is your full legal name, and what name would you like our staff to use?”
• Contact details: “What phone number and email address should we use for appointment messages?”
• Demographics: “What is your date of birth?”
• Insurance: “What is the member ID on your current insurance card?”
• Emergency contact: “Whom should we contact in an emergency, and what is that person's phone number?”
• Reason for the visit: “What is the main reason for your visit today?”
• Reason for the visit: “When did this concern begin, and what makes it better or worse?”
• Health history: “Which medical conditions has a clinician diagnosed?”
• Health history: “List any surgeries or hospital stays, with the approximate year.”
• Medications: “List each medication you take, with the dose and how often you take it.”
• Allergies: “Do you have any medication, food or material allergies, and what reaction did you have?”
• Consent to treat: “Do you consent to evaluation and treatment as described in this consent?”
• Financial policy: “Do you agree to the payment terms in the practice's financial policy?”
• Privacy notice: “Did you receive a copy of our notice of privacy practices?”

Specialty intake forms add questions that help that discipline prepare for its first visit. All ten specialties still need the practice's registration, policy and signature details alongside the clinical questions below.

• Medical intake forms add current conditions, past care, medications, family history and relevant screening questions.
• Dental intake forms add dental history, oral symptoms and medical conditions relevant to dental treatment.
• Therapy intake forms add the client's concerns, informed consent, telehealth terms and selected screening scales.
• Chiropractic intake forms add complaint history, pain details, accident information and informed consent.
• Physical therapy intake forms add referral details, injury history, function limits and the patient's goals.
• Pediatric intake forms add guardian details, birth and development history, minor consent and age-based screening.
• Med spa intake forms add treatment history, procedure consent, photo consent and aftercare acknowledgment.
• Massage therapy intake forms add pressure preferences, areas to treat or avoid and relevant health history.
• Optometry intake forms add eye history, current glasses or contacts and medical and vision insurance details.
• Direct primary care intake forms add a membership agreement alongside history, consents and screening.

To create an intake form, start with the information your staff already use and remove anything the practice cannot explain or act on. A practice manager can then build, test and publish the form in seven steps.

1. 1

   List what you collect today

   Gather every paper and PDF form, then mark where staff use each answer in scheduling, the visit, billing or follow-up.

2. 2

   Cut questions nobody reads

   Ask the front-desk lead and clinician to identify duplicate fields, unused questions and wording patients regularly ask staff to explain.

3. 3

   Group the rest into sections

   Put contact details, history, insurance, consents and policies in a clear order so patients see one subject at a time.

4. 4

   Make follow-up questions conditional

   In the form builder, show a follow-up only when an earlier answer makes that question relevant.

5. 5

   Mark what needs a signature

   Add typed or drawn signature fields to consents and policies, and identify whether the patient, representative, staff member or witness signs.

6. 6

   Test on a phone

   Have a front-desk lead complete every path on a phone, including a representative signature and any conditional medication or allergy questions.

7. 7

   Publish and send

   Publish the reviewed version, then send a private link or add the form to a packet. Existing documents can go through PDF and Word conversion before staff place fields.

Patients can fill out an Intake Pro intake form before a visit or at the front desk. Patients type or draw required signatures, and a parent or guardian can sign in the representative role when that person may act for the patient.

• Staff send a private link by text or email, and the patient opens that link on a phone, tablet or computer.
• The practice shows a QR code at check-in or on printed instructions so the patient can open the assigned form on a personal device.
• A practice can embed the form on its own website for patients who begin from the practice's online new-patient instructions.
• A paired front-desk kiosk lets the patient complete forms on a tablet, including offline, and clears the screen 60 seconds after submission.
• The patient or representative types or draws an e-signature; Intake Pro also supports staff member and witness signer roles.

When a HIPAA covered entity collects patient details on an intake form, the completed form contains protected health information. Under 45 CFR 160.103, a vendor storing those answers for the practice is a business associate.

This legal information is general. Confirm your practice's own obligations with its counsel or compliance lead.

HIPAA requires a covered entity to keep required documentation for six years from its creation or the date it was last in effect, whichever is later, under 45 CFR 164.530(j). Signed privacy acknowledgments and authorizations are part of that documentation.