Patient Forms Guide- Sample Forms and Use Cases

Recommended Reading

1. Patient Forms Introduction
2. Patient Forms Guide

Contents

1. How to create a COVID Screening form
2. How to create a demographics/insurance form

Custom Forms

There are many creative ways in which you can customize Patient Forms to collect more than just medical history. We have designed the "Other" question type with this goal in mind so that you can adapt the forms feature to your practice's needs. The following article reviews this process using two commonly used forms.

How to create a COVID Screening form

1. Click on “Create New Form >> Blank”.
2. Change the internal name from "(Blank") to “COVID-19 Screening” in the upper lefthand corner.
3. Change the title from “(Blank)” to “COVID-19 Screening”.
4. For the “Description”, copy in the following text:
   • We are going to ask you a few questions according to CDC guidelines to determine your risk for Coronavirus (COVID-19) 
5. Click “Add questions >> Other” multiple times to add multiple custom questions. Type in your own screening question prompts or copy and paste the suggested questions below; one prompt for each question:

• Have you traveled to any of the following countries in the last 14 days? China, Iran, Italy, Japan, South Korea, Other Countries
• In the past 14 days, have you had contact with anyone known to test positive for Coronavirus, COVID-19?
• Are you a healthcare worker who has been within 6 feet of a patient suspected of COVID-19 infection?
• Do you have an occupation where you are in close contact with large numbers of people each day like a Healthcare Facility, Retail Store, Public Transit, Food Industry or Airports?
• Do you currently have, or have you recently had, a fever?
• Do you have a cough?
• Are you feeling short of breath?
• Do you have any of the following underlying chronic medical conditions? (enter all that apply) Cancer, Heart Disease, ESRD, Liver Disease, Immune Disorder, Chronic Lung Disease, Immunosuppression, Asthma, COPD, Diabetes

6. Click “Save form” and then the back arrow at the top left corner of the page to complete. 

Set-up View

Patient's View

How to create a demographics/insurance form

1. Click on “Create New Form >> Blank”.
2. Change the internal name in the upper lefthand corner from "(Blank)" to a custom name.
3. Change the title from “(Blank)” to a custom name, ex. “Demographics and Insurance Form”.
4. For the “Description”, add a description and/or instructions to the patient.
5. Click “Add questions >> Other” for each custom question that you want to add to the form.
6. In the question prompt, enter your Demographics/Insurance related questions. Examples include:
   • Have there been any changes to your legal name?
   • What is your address?
   • What is your preferred phone number? What type of number is this? (home, mobile, etc.)
   • Who is your emergency contact and what is their contact information?
   • What is your insurance policy? (include insurance name, group number, and member/subscriber ID)
   • What is your preferred pharmacy? (name and address)
7. Click “Save form” and then the back arrow at the top left corner of the page to complete. 

Set-up View

Patient's View

Related Articles

• Patient Forms Introduction
• Patient Forms Guide
• Patient Forms - Frequently Asked Questions