Pre-Appointment Symptom Intake
Structured symptom capture before the visit – so the appointment starts at minute one.
5 questions · 1 page · about 3 minutes to answer · fully editable after you start
Appointment minutes spent reconstructing the history are minutes not spent on care. This pre-visit intake captures the story in the patient's own time: the main symptom and its duration, severity and pattern, what makes it better or worse, self-treatment tried, and the worry question that reveals what the patient actually needs addressed.
Clinicians reading it beforehand start at minute one with a hypothesis; the what-worries-you-most answer routinely redirects visits from the stated symptom to the real concern.
Replace [local emergency number, e.g. 000] and [local crisis line, e.g. Lifeline on 13 11 14] in its opening note with the services where your respondents live, before you share it: the numbers shown are Australia's. The Collect tab lists both until they are changed.
Template preview
This is a picture of every question as a respondent would see it, so nothing on it can be clicked or typed into. Use this template to get your own editable copy.
Opens in the Light theme, or in your own default theme if you have set one — change it anytime to any of the 4 built-in looks, or build your own on a paid plan.
Page 1
Before your appointment
This form asks about the problem you want to discuss at your appointment. Your answers help the clinician prepare and make the most of your time together. It takes about 3 minutes.
This form is not an emergency service. If you need urgent medical help or are in immediate danger, call [local emergency number, e.g. 000]. For crisis support, call [local crisis line, e.g. Lifeline on 13 11 14].
Q1.What is the main problem you want addressed?*
Q2.How long has it been going on?*
- Days
- Weeks
- Months
- A year or more
Q3.How severe is it at its worst?*
Q4.What makes it better or worse? What have you tried?
Q5.What worries you most about it?*
Where this template is used
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