Patient form templates and screening scales
Use these patient form guides to plan registration, health history, consent, policy, records and screening forms. Each scale guide covers item topics, scoring, ownership and licence terms.
Your practice builds each form in Intake Pro from the scale owner's wording or its own counsel-approved documents. Add the required signatures, publish the reviewed version and send it by link or kiosk.
Last updated
- Build paths Builder or file conversion
- Signatures Typed or drawn
- Delivery Private link or kiosk
- Scoring Weights and labelled bands
Which screening scale guides can you read?
The scale guides explain item topics, score calculations, screening bands, ownership and permission terms. Read the guide for the scale your clinical lead selects before building it with scored assessments.
PHQ-9
The PHQ-9 depression questionnaire: 9 items scored 0 to 27, with cut points at 5, 10, 15 and 20. How to send it online and score it automatically.
GAD-7
The GAD-7 anxiety questionnaire: 7 items scored 0 to 21, with cut points at 5, 10 and 15. How to send it online and score it automatically.
AUDIT-C
The AUDIT-C alcohol screen: 3 items scored 0 to 12, positive at 4 or more for men and 3 or more for women. How to add it to patient intake.
Epworth Sleepiness Scale
The Epworth Sleepiness Scale: 8 items scored 0 to 24, with 11 or more showing excessive daytime sleepiness. Scoring bands and how licensing works.
M-CHAT-R
The M-CHAT-R autism screen for toddlers 16 to 30 months: 20 yes or no items, three likelihood levels, and when the Follow-Up interview applies.
Vanderbilt Assessment Scales
The NICHQ Vanderbilt Assessment Scales for ADHD in children 6 to 12: a 55-item parent form and a 43-item teacher form, and who owns them.
What does each screening scale measure?
These scales have different respondents, score ranges and permission terms. The range describes the scoring materials; the clinical lead decides how the practice uses any result.
| Scale | What it screens for | Score range | Licence in brief |
|---|---|---|---|
| PHQ-9 | Depression over the last two weeks | 0 to 27 | No permission required |
| GAD-7 | Anxiety over the last two weeks | 0 to 21 | No permission required |
| AUDIT-C | Alcohol consumption | 0 to 12 | Public domain; avoid material changes |
| Epworth Sleepiness Scale | Usual daytime sleepiness | 0 to 24 | Copyright; licence required |
| M-CHAT-R | Autism likelihood in toddlers aged 16 to 30 months | 0 to 20 | Owner permissions; software or website licence |
| Vanderbilt Assessment Scales | ADHD and related concerns in children aged 6 to 12 | Symptoms 0 to 3; performance 1 to 5 | Check NICHQ and AAP terms |
What does each common patient form contain?
Common practice forms divide identity, clinical history, agreements and records permissions into separate documents. Your practice decides which fields and statements belong in its own intake forms.
| Patient form | Core contents |
|---|---|
| Patient registration | Identity, contact details, insurance, emergency contact and consent to treat |
| Health history | Conditions, medicines, allergies, surgeries, family history and habits |
| Privacy notice acknowledgment | Receipt of the practice's privacy notice, signer and date |
| Telehealth consent | Remote visits, privacy, technology, recording, fees and emergencies |
| Financial policy | Payment timing, insurance, missed visits, balances and refunds |
| Medical records release | Patient, recipient, records, purpose, authorization terms and signature |
Where can you read about each practice form?
The practice form guides provide field checklists and signature considerations for the documents in a new patient packet. Use your own approved wording for consents, notices, policies and record authorizations.
Patient registration form
What a patient registration form collects: identity, contact details, insurance, emergency contact and consent to treat. A field-by-field checklist.
Health history form
What a health history form covers: conditions, medications, allergies, surgeries, family history and habits, kept short with conditional questions.
Privacy notice acknowledgment
HIPAA asks providers to make a good-faith effort to get a written acknowledgment of the privacy notice. What the form says and how to keep it.
Telehealth consent form
What a telehealth consent form covers: how visits work, privacy, technology limits, recording, fees and emergencies. Check your state's rules.
Financial policy form
What a patient financial policy covers: payment at the time of service, insurance, missed visits, balances and refunds, plus a signature line.
Medical records release form
The six core elements and three required statements a HIPAA authorization to release medical records needs under 45 CFR 164.508, in plain English.
How do you turn a patient form into an online form?
A practice manager can build a form from its approved wording or convert the PDF or Word file already used at the front desk. Staff then configure fields, test the form and publish it for patients.
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Approve the source wording
Get scale wording from its owner and practice documents from your counsel-approved files.
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Build or convert the form
Use the form builder or PDF and Word conversion, then place fields after the file's malware scan.
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Add answers and signatures
Place answer fields and conditional follow-ups. Add typed or drawn signature fields for each required signer.
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Configure any scoring
Set the owner's weights, reverse scoring, subscales and labelled bands. Have the clinical lead review result handling.
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Test and publish
Check every answer path and scoring arithmetic with known answers. Publish only after the practice approves the form.
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Send it to patients
Use an intake packet, private text or email link, or paired front-desk kiosk.
Where should your practice get wording and permission?
Take each scale's current wording from its owner, and take practice policies and consent language from your own counsel-approved documents. Your practice must confirm licensing for its planned online use before publication.
The owner's current terms control electronic use, wording changes, software distribution and website posting. Read those terms before staff build the form and obtain any required permission.
Have counsel review practice policies and the clinical lead review health questions. Intake Pro keeps each signed version, PDF and audit trail for staff to handle under the practice's chart process.
Questions
Can a practice convert its existing Word patient forms?
Yes. Intake Pro scans and converts the uploaded file, then staff place fields before publishing. The practice approves its wording and permission to use it.
How do patient form packets handle signatures?
The patient opens one packet link and signs each form in turn. Intake Pro retains typed or drawn signatures with the published version, PDF and audit trail.
Who approves a screening scale before patients receive it?
The practice manager confirms wording and licensing. The clinical lead reviews scoring and staff procedures, and staff test known answers before publication.
Can patients complete screening scales at the front desk?
Yes. Patients can use a paired kiosk that works offline and clears 60 seconds after submission. Staff can also send a private link before the visit.