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Patient Information Form Template

This patient information form template is designed for doctors, hospitals, therapists, and clinics to gather the essential information needed for patient treatment. By using it, you’ll be able to maintain a central database of all your visiting patients. It’s conversational UI makes the form filing experience engaging for the patients and their caretakers.

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Features of Patient Information Form Template

Streamline patient information collection with this template


Who can use this Patient Information Form Template?



This form help doctors to gather information regarding a patient’s medical history, allergies, medications, and current health concerns. This data assists them in diagnosing patients, formulating treatment plans, and monitoring the effectiveness of treatments.


Upon admission, hospitals can use this form to collect essential patient information such as demographics, insurance details, and emergency contact information. This information is crucial for efficient record management, accurate billing, and ensuring patients receive appropriate care during their stay.


This form can help dentists to gather data on patients’ past dental procedures, daily oral hygiene routines, and any existing dental concerns. This information is essential for providing patients with tailored dental care and addressing any oral health issues effectively.


This form helps nurses to maintain accurate and up-to-date patient health records. They can document their observations, assessments, and patients’ responses to treatments. This documentation ensures patients receive the necessary and appropriate care.


Therapists can gather information about patients’ physical capabilities, mental health history, and desired outcomes from therapy. This information empowers therapists to develop personalized treatment plans and track patients’ progress throughout their therapeutic journey.

Suggested Template – Patient Satisfaction Survey Template


Benefits of Patient Information Form Template


Use the form offline

By installing the Surveysparrow app on a tablet, users can access and utilize the form seamlessly without the need for an internet connection. This feature ensures that patient information can be collected efficiently, regardless of connectivity issues.

Collect digital signatures

The form supports various methods for respondents to provide their signatures, including the options to draw, type, or upload digital signatures. This flexibility facilitates a more accessible and user-friendly way for patients to consent and verify their information securely.

Mobile-Friendly Design

With its responsive design, the form is accessible on any device, regardless of screen size. This ensures that patients (or their caretakers) can fill out their information comfortably from their smartphones, tablets, or computers, enhancing the overall user experience.

Skip/Display Logic

The form is personalized through skip/display logic, which dynamically changes the next fields based on previous responses. This feature makes the form more interactive and tailored to each individual, avoiding irrelevant questions and streamlining the process of data collection.

Multiple Formats

Patients have the option to choose between a single-page format, where all fields are displayed on one page, and a conversational format, which presents each field on a separate screen. This allows for flexibility in how information is collected, catering to different user preferences.

HIPAA Compliance

SurveySparrow is a HIPAA compliant platform, adhering to the stringent privacy and security standards required in healthcare. This compliance guarantees that patient information is handled with the utmost care and confidentiality, safeguarding against unauthorized access and breaches.


How to use this template?


Step 1: Customize the template

Personalize your patient info form to match your brand by adjusting design elements like background colors, fonts, and adding video backgrounds with SurveySparrow. Enhance clarity with the AI Wing feature for question refinement and customize welcome and thank you pages.

Step 2: Integrate with other tools

Easily integrate the form with your workflow and third-party apps like Google Sheets and Mailchimp. Google Sheets integration allows you to automatically transfer collected data at one place, simplifying data organization. With Mailchimp integration, send newsletters or other health-related information to your patients directly through the platform, saving you time and effort.

Step 3: Share the form

Share the form through email, SMS, direct links, or embed it on your website. Additionally, generating a QR code can provide instant access, offering flexibility and convenience to both the healthcare provider and the patients.

Step 4: Analyze the results

Gain valuable insights from the patient information you collect. Monitor form submissions and analyze data in real-time. You can also export your responses to a CSV format for further analysis. The dashboard also offers filter and widget functionalities, allowing you to explore your data effectively and gain deeper insights into your patient population.

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