On a scale of one to ten, how healthy are you today?
A self-rating is not a screening decision and invites judgments nobody can act on. Ask a yes-or-no question tied to the decision instead.
Healthcare & MedicalForms
Health screening form: write the decision rule first
A health screening form asks a few time-bound questions that help decide whether someone goes ahead with a visit, a shift or an activity, or needs a person to review the answers first. It does not diagnose anyone, and a no answer does not mean the person is medically cleared. Before you publish, write down which answers pass, which go to review and who reviews them, then have counsel check the wording for the group you screen.
What people search
Health screening form: 170 average monthly searches.Google Ads Keyword Planner · 2026-10-09 · United States
Questions to leave out
Questions a screening should not ask
Which doctor or clinic did you see most recently?
Naming another provider adds third-party information that the decision does not use.
Are you pregnant or planning a pregnancy?
Pregnancy status is sensitive. When a screening covers staff or program participants, it can create discrimination risk. Remove it unless counsel approves a specific, lawful use.
Please describe any test results or vaccination records you have.
Ask whether a yes-or-no condition applies, not for the underlying record. Collecting records adds storage and deletion duties you may not be ready to carry.
Field blueprint
Screening questions tied to one decision
| Field | Type | Required | Why you ask it |
|---|---|---|---|
Full name | Short text | Required | Ties the answers to a person, so the reviewer can follow up through the process you approved. |
Date of screening | Date | Required | Ties the answers to a day. A question that looks back over a set period only makes sense with a fixed date. |
Who is completing this formI am the person being screenedI am completing this for someone else | Single choice | Required | Shows whether the answers come from the person being screened. If someone else answers, the reviewer decides whether that is acceptable. |
Reason for the screeningClinic visitProgram or classSite or event accessOther (describe in the concerns box) | Dropdown | Required | Ties the answers to the one decision that uses them, so a single rule does not stretch across unrelated purposes. |
Clinician advice to stay away from othersYour clinical lead sets the wording and the time window. Choose Not sure if you do not know. YesNoNot sure | Single choice | Required | A yes or not-sure answer needs a person's review. The form does not make that decision itself. |
New symptoms since your last screeningAnswer yes if you have noticed anything new. Do not describe it here. YesNoNot sure | Single choice | Required | Shows a change a reviewer should look at. The detail is gathered by a clinician or reviewer, not on this form. |
Concerns for the reviewerKeep it brief. Leave out diagnoses, test results and medicine names unless your process asks for them. For example: I am here for a scheduled visit. | Long text | Optional | Gives the reviewer context for a yes or not-sure answer. |
Mobile phone | Phone | Required | Lets the reviewer call back when an answer needs a conversation before a decision is made. |
Email addressOptional. | Optional | A second contact route for a follow-up that is not urgent. | |
Confirm your answers | Section header | Separates the questions from the final step. | |
Answers confirmedI confirm these answers are correct as of the screening date | Multiple choice | Required | Keeps the final step deliberate, so the person reads the answers before they submit. |
Words for the respondent
Introduction, result message and help text
Introduction
Answer for the date shown. This is a short screening, not a medical evaluation. A yes or not-sure answer means a person reviews it before any decision is made. If you have an emergency, call your local emergency number instead of using this form.
Confirmation
Thank you. Your answers were received. If the reviewer needs more information, they will contact you using the phone number you gave.
Clinician advice to stay away from others
If you are not sure, choose Not sure. A reviewer will ask the next question.
New symptoms since your last screening
Answer yes if you have noticed anything new. Do not describe it on this form.
Concerns for the reviewer
Keep to the reason you are here. Leave out diagnoses, test results and medicine names.
Try it
Preview the screening as the person will see it
After a response arrives
Decide what happens after each answer
Write the decision rule before you publish
Decide which answers pass, which go to review and who does the reviewing. The form shows each submission; it does not make the decision for you, so the rule must exist before the first submission arrives.
Plan around the processing schedule
Each answer waits for the hourly production run before the form's creator is notified. Send the link early enough for that run plus your own review, before the visit, shift or event.
Tell people what a review looks like
A person who is sent for review should know who will contact them, when, and what the review covers. Put that in the confirmation text so the wait does not feel like a silent refusal.
Limit who can export screening answers
The CSV export contains every answer and the phone numbers. Limit who can export it, delete copies on your own schedule, and keep them out of shared folders.
Frequently asked questions
What is a health screening form?
It is a short set of questions that helps decide whether someone should go ahead with a visit, a shift or an activity, or whether a person should review the answers first. It does not diagnose anyone, and a no answer does not mean the person is medically cleared.
Is a health screening questionnaire the same as a medical history form?
No. A screening asks about one decision over a short time window. A medical history is a longer clinical record, and it belongs in a separate process that a clinician or the clinic owns.
Can I use a health screening form template for employees?
Be careful. Medical questions for staff can be restricted by disability and privacy law, and the answers are sensitive. Have counsel review the questions and the decision rule before you use the form with employees, and remove any question they do not approve.
Should a screening form ask the person to sign a statement?
That is for your counsel and clinical lead to decide. Any signed statement needs its own approved process, kept apart from the screening questions so the two are not confused.
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