Health screening form
A health screening form is a record of what someone reported on a given day, not a medical assessment. This form asks the facts you need before someone arrives — temperature, symptoms, travel in the past week — and stores every answer timestamped, so you can see who reported what and when. The form does not diagnose or recommend treatment; the owner sets the policy for what happens next.
The form beside this text is live. Fill it in and submit it — it validates exactly as it would for a real respondent, and saves nothing.
Symptom checkboxes let people report more than one
A checkbox group for symptoms means someone with both fever and cough can report both rather than choosing one. A single response carries every symptom they marked, so your record is complete instead of partial.
Every response is timestamped
Each screening is recorded with the exact time it was submitted. If you need to review screening history or match a response to an event, the timestamp is what connects them — and it is part of the record from the moment someone submits.
No card required.
Health Screening Form
Live previewHow to build this form
5 steps in the editor. Nothing here needs a paid plan.
- Add text and email fields for the person's name and contact.
- Add a number field for temperature reading, marked optional, and a set of symptom checkboxes (fever, cough, sore throat, fatigue, none).
- Add two radio groups: one for recent exposure risk (low, moderate, high) and one for travel in the past week (yes, no).
- Add an optional textarea for additional notes, and a required confirmation checkbox stating they are answering truthfully.
- Share the form's link or embed it at checkin. Export responses to CSV to track screening history.
Fields in this form
8 fields, using 6 of the 19 field types available.
| Question | Field type | Required |
|---|---|---|
| Full name | Short text | Yes |
| Yes | ||
| Temperature (°F) | Number | Optional |
| Any of these symptoms today? | Checkboxes | Optional |
| Exposure to illness in the past week? | Radio buttons | Yes |
| Travel in the past week? | Radio buttons | Yes |
| Additional health notes | Long text | Optional |
| Consent | Checkboxes | Yes |
What goes wrong with this form
Specific to a health screening form, not general advice about forms.
Treating the form as a replacement for medical judgment
This collects self-reported data, not verified medical facts. A temperature reading is what someone says it is; symptoms are what they report. Any decision based on these answers remains the owner's responsibility, and the form does not replace a medical professional's assessment.
No clear follow-up policy
Collecting screening data without a published policy for how answers are used leaves respondents guessing and exposes you to liability. Publish what you will do if someone reports high temperature or multiple symptoms before they fill it out.
Making all fields required
Temperature and some symptoms are often optional — not everyone has a thermometer on hand, and asymptomatic people should still be able to complete screening. Mark only what is genuinely necessary as required, typically just name and the confirmation that answers are truthful.
Questions about this form
Is this a medical assessment or diagnosis tool?
No. This form collects what someone reports about their current health — temperature, symptoms, travel history — on a specific day. It is a screening record, not a medical evaluation, and the owner of the form sets the policy for how the answers are used. The respondent remains responsible for disclosing their actual health status.
Can I require someone to report a specific temperature?
You can ask for a temperature reading, but the form does not enforce a limit or recommend a course of action based on it. The number is stored as data you can review; you remain responsible for deciding what it means and what to do next.
What should I do if someone reports symptoms?
That is your decision to make based on your own policies and local guidelines. The form collects the report; the owner decides how to respond — whether to defer the visit, recommend isolation, escalate to a medical provider, or take another action. The form does not make that decision for you.
Other templates
- Patient intake formInsurance provider and ID as their own fields, so registering doesn't start with a phone call.
- Medical HistoryCollect a new patient's medical background before the first appointment.
- Insurance VerificationCollect insurance details before the appointment so staff can verify coverage manually.