Screening Form Template

✓ No credit card required
✓ No time limit on Free plan

Are you coming to visit?What's your full name?When will you be visiting?Have you traveled to a high-risk country in the last 14 days? Have you been in close contact with anyone who has traveled to a high-risk country within the last 14 days?Have you experienced any symptoms of COVID-19 in the last 14 days?Symptoms include fever, cough, shortness of breath and other respiratory problems.Have you been in contact with anyone in the last 14 days who is experiencing any of those symptoms?Have you had close contact with someone who tested positive for COVID-19 within the last 14 days?We might need to give you a quick call to clarify some things. Where can we reach you?And what's your email address?Thanks for your time!

Rated 4.5 out of 600+ reviews on G2.com

Simplify health screenings

Got visitors coming to your office or organization? You want to make sure they're healthy and haven't been to any high-risk areas. This screening form will take them only a minute to fill in, so you'll get notified straight away if any risks crop up.

Screening form FAQs:

Before you send out your form, there are two things you should do:

Set up a BAA (Business Associate Agreement) with us

Typeform is a HIPAA-compliant company, so all the healthcare-related info you process with us is legally airtight. But for you to be 100% HIPAA compliant, you’ll first need to set up a BAA. To do this you would need to talk to us about our enterprise plan, which you can do by filling out this Typeform, or contacting your Typeform account manager.

Check the local data collection laws

Data collection laws aren’t a one-size-fits-all thing—especially when there’s sensitive medical info involved. So before hitting share, seek advice from a local lawyer to make sure you’ve covered everything.

Make it uniquely yours

Customize to your heart's content: backgrounds, Google fonts, colors, buttons, and more.

Choose from thousands of beautiful images, videos, and icons. Or use your own.

Create beautiful forms with zero coding required.

Get started — it's free

Make life easy with integrations

Google Sheets

Salesforce

Slack

Google Analytics

Zapier

HubSpot

Here's what people say about us

Form builders are as old as the web, but Typeform elevates the medium substantially.
Johnny Rodgers
Product Architect

We’ve received 3x the responses using Typeform than from a professionally commissioned market research study
Kate Donhoe
Head of Product Marketing

Leads from the Typeform integration were twice as likely to convert.
Tobias Wasmer
Marketing Manager @ Volvo Cars

You used to need developers to do all this. Not anymore.
Kyle Maltz
Chief Operating Officer

Typeform is a production-grade system for our entire growth funnel.
Gaurav Vohra
Head of Growth

Typeform helps me attract more responses and a higher response rate than other tools.
Rand Fishkin
CEO + Founder

Form builders are as old as the web, but Typeform elevates the medium substantially.
Johnny Rodgers
Product Architect

We’ve received 3x the responses using Typeform than from a professionally commissioned market research study
Kate Donhoe
Head of Product Marketing

Leads from the Typeform integration were twice as likely to convert.
Tobias Wasmer
Marketing Manager @ Volvo Cars

You used to need developers to do all this. Not anymore.
Kyle Maltz
Chief Operating Officer

Typeform is a production-grade system for our entire growth funnel.
Gaurav Vohra
Head of Growth

Typeform helps me attract more responses and a higher response rate than other tools.
Rand Fishkin
CEO + Founder

Form builders are as old as the web, but Typeform elevates the medium substantially.
Johnny Rodgers
Product Architect

We’ve received 3x the responses using Typeform than from a professionally commissioned market research study
Kate Donhoe
Head of Product Marketing

Leads from the Typeform integration were twice as likely to convert.
Tobias Wasmer
Marketing Manager @ Volvo Cars

You used to need developers to do all this. Not anymore.
Kyle Maltz
Chief Operating Officer

Typeform is a production-grade system for our entire growth funnel.
Gaurav Vohra
Head of Growth

Typeform helps me attract more responses and a higher response rate than other tools.
Rand Fishkin
CEO + Founder

87% of users reported higher completion rates after switching to Typeform

How does it work?

Make a stylish form in minutes with our intuitive builder.

Choose from different question types: Multiple Choice, Rating, Opinion Scales, and more.

Take respondents down different paths based on their answers.

Screening form not right?

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Screening Form Template

Simplify health screenings

Screening form FAQs:

What should I consider before using this healthcare form?

How can I easily conduct health screenings for upcoming visitors?

Make it uniquely yours

Make life easy with integrations

Here's what people say about us

How does it work?

Screening form not right?

Other categories used by people like you