Pre-Visit Health Screening Template
This form collects contact details and basic symptom, exposure, and travel information before an in-person visit. Clinics use it to decide whether to confirm or reschedule an appointment.
When to use it
- Before a patient arrives for an in-person appointment
- When checking for fever or a new or worsening cough
- After a reported exposure to a contagious illness
- When clinic staff may need to reschedule based on screening answers
What it asks
- What is your name?
- What phone number can we reach you at?
- What is your email address?
- Do you currently have a fever?
- Do you currently have a new or worsening cough?
- Have you recently been exposed to someone with a contagious illness?
- Have you traveled recently?
- I understand the clinic may ask me to reschedule based on my answers.
Why it should be encrypted
Symptom, exposure, and travel answers are personal health information, alongside identifying contact details. They should be readable only by the clinic staff who need them; SealForm cannot read the answers.
Tips
- Set a clear time period for what counts as recent exposure or travel.
- Tell respondents how and when clinic staff will contact them about rescheduling.
- Limit access to completed responses to staff who handle appointment screening.