Use our readymade template to create this Google form. Customize it further using our form builder.
Create your intake form
- Use prebuilt template to create a HIPAA compliant online podiatry intake form
- Collect patient, demography, emergency contact details, medical history
- Collect foot-related concerns, pain level, and lifestyle impact
- Allow patients to upload their driver’s id, prescriptions for medications
- Get signatures for consent for treatment, notice of privacy practices, use of PHI
Collect responses from your patients
| Patient ID | user input |
| Patient Name | user input |
| Patient Email | user input |
| Patient Phone Number | user input |
| Marital Status | user input |
| Date of birth | user input |
| Address | user input |
| Emergency Contact Name | user input |
| Emergency Contact Phone | user input |
| Relationship | user input |
| Primary Doctor | user input |
| Location | user input |
| Date of service | user input |
| Primary Insured (subscriber) | user input |
| Relationship to Patient | user input |
| Date of Birth | user input |
| Phone number | user input |
| Subscriber Employer or Plan Sponsor | user input |
| Insurance Company | user input |
| Subscriber ID# | user input |
| Secondary Policy Holder Name | user input |
| Date of Birth | user input |
| Subscriber Employer or Plan Sponsor | user input |
| Phone number | user input |
| Insurance Company | user input |
| Patient Signature | user input |
| Date signed | 2023-08-08 |
| What are the medical issues concerning your foot, ankle and legs? | user input |
| Result of accident or work injury? | No |
| On a scale of 1-10, what is your level of pain? | user input |
| Pain Type: | user input |
| Since the time your pain or problem began, has it: | user input |
| How has this problem affected your lifestyle or ability to work? | user input |
| Have you visited a podiatrist before? | user input |
| Name of the podiatrist | user input |
| Last appointment date | user input |
| Are you a diabetic? | No |
| What athletic activities do you participate in and how often? | user input |
| Do you get leg cramps after activity? | No |
| Does foot pain limit your desired activities? | user input |
| Do you have any difficult walking? | user input |
| Any pain in the calves or buttocks when walking? | user input |
| Which of these foot problems do you have or had in the past? | Corns/Calluses,Fungal Toenails |
| Are you currently experiencing any of the following symptoms? | Fever,Muscle aches |
| Are you currently in good health? | Yes |
| Are you under the care of a physician? | No |
| Have you or any family member had or currently have any of these medical conditions: | High Blood Pressure,Diabetes |
| Have you had any serious illness/operation/ or been hospitalized? | No |
| Are you currently taking any medications? | No |
| Upload prescriptions | user input |
| Do you have any allergies? | user input |
| List any allergies you may have | user input |
| Do you use, or have you in the past, used any of the following products: | Tobacco,Alcohol |
| Smoking Status | Never smoked |
| Alcohol Intake | None |
| Are you or could you be pregnant/nursing? | No |
| Patient Signature | user input |
| Date Signed | 2023-08-08 |
| Patient Signature | user input |
| Date Signed | 2023-08-08 |
| Date Signed | user input |
- Pre-populate patient details from your booking system to reduce errors
- Send an email invitation with a secure link for patients to complete their intake
- Allow patients to save their progress and complete their form at a later time
- Set up an email template and send invitation emails to multiple patients with ease
- Send an email to the patients with a copy of their response when they submit the form
Track patient responses in Google Sheets
- Export patient responses to Google Sheets for easy record-keeping
- Create a custom workflow and manage your patient intake efficiently
- Use pre-built reports to easily keep track of patient progress over time
- Receive a copy of the response by email when a patient submits the intake form
- Use data in Google Sheets to integrate with EHR systems for seamless data transfer
HIPAA compliance
| Patient ID: | ****** |
| Patient Name: | ****** |
| Patient Email: | ****** |
| Patient Phone Number: | ****** |
| Marital Status: | user input |
| Date of birth: | 11/30/1899 |
| Address: | user input |
| Emergency Contact Name: | user input |
| Emergency Contact Phone: | user input |
| Relationship: | user input |
| Primary Doctor: | user input |
| Location: | user input |
| Date of service: | 11/30/1899 |
| Primary Insured (subscriber) : | user input |
| Relationship to Patient: | user input |
| Date of Birth: | 11/30/1899 |
| Phone number: | user input |
| Subscriber Employer or Plan Sponsor: | user input |
| Insurance Company: | user input |
| Subscriber ID#: | user input |
| Secondary Policy Holder Name: | user input |
| Date of Birth: | 11/30/1899 |
| Subscriber Employer or Plan Sponsor: | 11/30/1899 |
| Phone number: | user input |
| Insurance Company: | 11/30/1899 |
| Date signed: | 8/8/2023 |
| What are the medical issues concerning your foot, ankle and legs?: | user input |
| Result of accident or work injury?: | No |
| Pain Type:: | user input |
| Since the time your pain or problem began, has it:: | user input |
| How has this problem affected your lifestyle or ability to work?: | user input |
| Have you visited a podiatrist before?: | user input |
| Name of the podiatrist: | user input |
| Last appointment date: | 11/30/1899 |
| Are you a diabetic?: | No |
| What athletic activities do you participate in and how often?: | user input |
| Do you get leg cramps after activity?: | No |
| Does foot pain limit your desired activities?: | user input |
| Do you have any difficult walking?: | user input |
| Any pain in the calves or buttocks when walking?: | user input |
| Which of these foot problems do you have or had in the past?: | Corns/Calluses, Fungal Toenails |
| Are you currently experiencing any of the following symptoms?: | Fever, Muscle aches |
| Are you currently in good health?: | Yes |
| Are you under the care of a physician?: | No |
| Have you or any family member had or currently have any of these medical conditions:: | High Blood Pressure, Diabetes |
| Have you had any serious illness/operation/ or been hospitalized?: | No |
| Are you currently taking any medications?: | No |
| Upload prescriptions: | user input |
| Do you have any allergies? : | user input |
| List any allergies you may have: | user input |
| Do you use, or have you in the past, used any of the following products:: | Tobacco, Alcohol |
| Smoking Status: | Never smoked |
| Alcohol Intake: | None |
| Are you or could you be pregnant/nursing?: | No |
| Date Signed: | 8/8/2023 |
| Date Signed: | 8/8/2023 |
| Date Signed: | 11/30/1899 |
- Create a HIPAA compliant intake form to safely collect, store and access patient responses
- Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
- Mask PHI fields when exporting form responses to Google Sheets and sending them on email
- Pre-populate patient details in intake forms by creating secure prefill links without exposing PHI
- Limit access to patient data only for authorized personnel and minimize risk of data breaches
These reviews are reproduced without modification from Google Workspace Marketplace.
July 27, 2023
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July 23, 2023
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February 16, 2024
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— Myles Sicuro
October 31, 2023
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July 12, 2023
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November 27, 2023
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July 10, 2023
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