Telehealth Visit Pre-Screening Form

Telehealth Visit Pre-Screening Form — Form Fields

This healthcare template includes 9 fields. Collect patient chief complaint and preliminary health information before a scheduled telehealth appointment. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Email Address (email, required)
• Date of Birth (text, required)
• Appointment Date and Time (text, required)
• Reason for Today's Visit (dropdown selection, required) — options: New symptom, Follow-up on existing condition, Medication refill, Lab result review, Mental health check-in, Prescription question, Other
• Please describe your current concern (long text, required)
• Are you experiencing any of the following urgent symptoms? (multiple choice, required) — options: Chest pain or difficulty breathing, Severe pain, High fever (over 103F), None of the above
• Has your current medication list changed since your last visit? (multiple choice, required) — options: Yes, No
• List any new medications or changes (long text, optional)