1
Full name or organisation name
RequiredProvides a structured answer that is straightforward to compare and segment. It is required in this starting template, but you can change that in the builder.
Healthcare template
Clinic patient intake
Collect the essential background and requirements for your upcoming clinic visit.
4 minute estimate5 fully editable questionsNo account needed to preview
Full question preview
What this template asks
2
Email address
RequiredCollects contact information only where the follow-up purpose has been explained. It is required in this starting template, but you can change that in the builder.
3
Which option best describes your need regarding your upcoming clinic visit?
RequiredProvides a structured answer that is straightforward to compare and segment. It is required in this starting template, but you can change that in the builder.
InformationAssessmentDirect supportFollow-upOther
4
Please describe your goals, needs or relevant background.
RequiredCaptures context, examples, and ideas that fixed options may miss. It is required in this starting template, but you can change that in the builder.
5
I consent to being contacted about this submission.
RequiredRecords an explicit participation decision before continuing. It is required in this starting template, but you can change that in the builder.
Sample-size considerations
Follow the study protocol and applicable ethics requirements. Clinical or sensitive health studies normally require specialist review beyond a general survey template.
Best practices
Minimise health identifiersExplain confidentiality and limitsProvide an urgent-care route outside the survey
Common mistakes
Using a survey as emergency clinical supportCollecting diagnoses without safeguardsMaking medical claims from an unrepresentative sample
Frequently asked questions
Can I edit the clinic patient intake template?
Yes. Every question, answer option, required setting, section, theme, and eligible logic rule can be changed in Surveyor before you publish.
Can I preview the questionnaire before signing up?
Yes. The respondent preview is available without an account. An account is required only when you want to create and save an editable survey in a protected workspace.
Last reviewed 2 August 2026
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