Podiatry intake form
21 reviews
21K+
Installs

Use our readymade template to create this Google form. Customize it further using our form builder.

Create your intake form

Assessment form builder
  • navigate_next Use prebuilt template to create a HIPAA compliant online podiatry intake form
  • navigate_next Collect patient, demography, emergency contact details, medical history
  • navigate_next Collect foot-related concerns, pain level, and lifestyle impact
  • navigate_next Allow patients to upload their driver’s id, prescriptions for medications
  • navigate_next 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
  • navigate_next Pre-populate patient details from your booking system to reduce errors
  • navigate_next Send an email invitation with a secure link for patients to complete their intake
  • navigate_next Allow patients to save their progress and complete their form at a later time
  • navigate_next Set up an email template and send invitation emails to multiple patients with ease
  • navigate_next Send an email to the patients with a copy of their response when they submit the form

Track patient responses in Google Sheets

Assessment form builder
  • navigate_next Export patient responses to Google Sheets for easy record-keeping
  • navigate_next Create a custom workflow and manage your patient intake efficiently
  • navigate_next Use pre-built reports to easily keep track of patient progress over time
  • navigate_next Receive a copy of the response by email when a patient submits the intake form
  • navigate_next 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
Patient Signature:
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
Patient Signature:
Date Signed:8/8/2023
Patient Signature:
Date Signed:8/8/2023
Date Signed:11/30/1899
  • navigate_next Create a HIPAA compliant intake form to safely collect, store and access patient responses
  • navigate_next Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
  • navigate_next Mask PHI fields when exporting form responses to Google Sheets and sending them on email
  • navigate_next Pre-populate patient details in intake forms by creating secure prefill links without exposing PHI
  • navigate_next 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

5 stars

I am 100% a fan of this company. We use HIPAA compliant Google Forms and needed a way to collect signatures, the industry standard company is TOO expensive. I started using FormEsign and it worked perfectly. It lacked the ability to provide a pdf copy of the form after signature. This company worked with me help their product evolve into something that could benefit all future clients AND the end user. The team was polite, professional, kind, enthusiastic, and willing to make a change. This earned my loyalty. I will sing their praises. Good work, and thank you!

— Royal Bush

July 23, 2023

5 stars

I am not tech savvy. I chose formesign to help create registration links for clients. Vipid has been great in assisting me. He goes above and beyond. My company now has moved from the stone age to modern age through the ability to use this feature. Of the many features I am impressed with, the ability to update a form without needing to regenerate a link is amazing. I often make mistakes and that ability allows me to fix mistakes without needing to change everything. Thank you!!!

— Sol Evans

February 16, 2024

1 stars

Does not work

— Myles Sicuro

October 30, 2023

5 stars

We needed a way to create forms with e-signatures and this app made it very easy. Support is also very quick and always helpful. Cannot recommend enough!

— Chris Henesy

July 12, 2023

5 stars

It very friendly to used. I love it. For my case multiple signature needed. it's supporting

— Senthil Kumar

November 27, 2023

5 stars

Yeah this is good for all

— luqman khan

July 10, 2023

5 stars

We were looking for a way to have a signature option in our form. Formesign addon allowed us to collect signatures for the acknowledgment and consent forms. It was simple and easy to setup. Very useful addon for google forms.

— Joan S

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