- Ambulance Checklist Form
- Ambulance Transfer Form
- Authorization for Disclosure of Protected Health Information
- Blood Donation Form
- Body Measurement Form
- Cancel Appointment Form
- Caregiver Consent Form
- Child Assessment Form
- Child Care Authorization Form
- Child Care Emergency Form
- Chiropractic Intake Form
- Dental Assessment Form
- Dental Assistant Evaluation Form
- Dental Claim Form
- Dental Clearance Form
- Dental Enrollment Form
- Dental Estimate Form
- Dental Examination Form
- Dental Insurance Form
- Dental Procedure Medical History Form
- Dental Records Release Form
- Dental Referral Form
- Dental Reimbursement Form
- Dental Screening Form
- Dental Treatment Consent Form
- Dental Treatment Plan Form
- Dentistry Contact Form
- Doctor Appointment Form
- Doctor Diagnosis Form
- Doctor Referral Form
- Drug Prior Authorization Request Form
- Emergency Contact Form
- Endodontist Patient Registration Form
- Endodontist Referral Form
- Enrollee Prescription Drug Claim Form
- Facial Intake Form
- First Aid Checklist Form
- Flu Vaccine Consent Form
- General Dentist Patient Registration Form
- Health Assessment Questionnaire
- Health Evaluation Form
- Health Insurance Claim Form
- Health Insurance Evaluation Survey
- Health Insurance Marketplace Statement
- Health Screening Form
- Home Delivery Pharmacy Prescription Order Form
- Hospital Admission Form
- Hospital Discharge Form
- Hospital Evaluation Form
- Hospital Patient Satisfaction Survey
- Hospital Registration Form
- Immunization Exemption Form
- Immunization Record Form
- Immunization Waiver Form
- Indemnity Form
- Informed Consent Form
- Laboratory Test Request Form
- Massage Therapy Intake Form
- Medicaid Application Form
- Medicaid Complaint Form
- Medicaid Transportation Form
- Medical Card Application Form
- Medical Consultation Form
- Medical Declaration Form
- Medical Examination Form
- Medical History Form
- Medical Information Form
- Medical Permission Form
- Medical Record Transfer Request
- Medical Records Release Form
- Medical Records Request Form
- Medical Reimbursement Bill Form
- Medical Reimbursement Claim Form
- Medical Release Form
- Medical Summary Form
- Medicare Application Form
- Medication Administration Record
- Medication List Form
- Medicine Order Form
- Mental Health Intake Form
- Newborn Questionnaire
- Nursing Assessment Form
- Nursing Home Application Form
- Nutrition Consultation Form
- Occupational Therapy Progress Note
- Online Bill Payment
- Online Medical Questionnaire
- Ophthalmology Referral Form
- Oral Surgery Patient Registration Form
- Oral Surgery Referral Form
- Organ and Tissue Donation Form
- Organ Donation Form
- Pathology Request Form
- Patient Admission Form
- Patient Appointment Request Form
- Patient Assessment Form
- Patient Demographic Form
- Patient Discharge Form
- Patient Exit Survey
- Patient History Form
- Patient Intake Form
- Patient Note Entry Form
- Patient Nutrition Assessment Form
- Patient Pain Assessment Form
- Patient Progress Tracking
- Patient Registration Form
- Patient Revocation Request Form
- Patient Satisfaction Survey
- Patient Survey Questionnaire
- Pediatric Consent Form
- Pedodontic Patient Information Form
- Periodontal Referral Form
- Permission To Treat Form
- Personal Representative Request
- Pharmacy Complaint Form
- Pharmacy Registration Form
- Physical Exam Form
- Physical Therapy Evaluation Form
- Physician Referral Form
- Police Medical Questionnaire
- Prescription Drug Claim Form
- Prescription Form
- Prescription Refill Request Form
- Proof Of Immunization Form
- Psychiatric Evaluation Form
- Psychotherapy Intake Form
- Referral Request Form
- Request a Routine Medical Appointment
- Request for Access to Protected Health Information
- Request for Accounting
- Request for Confidential Communications
- Request for Diagnosis and Treatment Code Information Form
- Request for Restriction of Use and Disclosure of PHI
- Request Routine Dental Appointment Form
- Request to Amend Protected Health Information
- Request to Inspect a Copy of Clinical Record
- Request to Obtain a Copy of Clinical Record
- Request to Restrict the Use of Confidential Information
- Safety Declaration Form
- School Medication Form
- School Medication Record
- Self Referral Form
- Sports Physical Form
- Statement of Disagreement
- Student Health Record Form
- Student Insurance Claim Form
- Test Report Form
- Universal Medication Form
- Veterinary Prescription Form
- Veterinary Release Form
- Weight Loss Tracking Form
- Wound Assessment Form
Health Survey
Add this health survey template to your website and modify it as you see fit. You can use this template to collect accurate information on health from other people.
Customize template
See howThe above health questionnaire example is waiting for your personal touch. Go ahead and adapt this form template into an insightful survey about health that enhances patient care. Users in over 185 countries trust 123FormBuilder to build reliable, flexible forms with no need for programming skills. Once you set up your initial health survey questions, you can clone the first form to serve other specialties, such as an oral health survey, a family health survey or a public health survey.
Publish template
See how123FormBuilder's web forms are mobile-friendly and look great on any device. Instantly publish your hospital survey to your website with nothing more than a copy/paste. If social media is part of your healthcare survey research methods, share your world health survey in multiple languages on Facebook, Twitter, and more!
Collect & manage data
See howThe simplicity of implementing 123FormBuilder as your health survey provider masks the advanced security and features it offers. Submissions are stored in a database and can be exported to CSV, PDF and Excel. Or you can create and share graphs and reports that help facilitate discussions of trends revealed by an annual health survey.
Optimize your flow
See howCollaboration has never been easier. Let’s say you’re working on a health insurance survey. You can have submissions notify team members at both the insurance company and the healthcare provider in real time. The health survey results can even be sent to a file sharing platform such as Dropbox or Google Drive.
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