Health Screening Questionnaire

Paper screening has a familiar rhythm: a clipboard at the front desk, a queue forming while someone reads symptom questions out loud, and a stack of completed sheets that nobody looks at until the person is already inside. The one answer that matters, a Yes to fever or recent contact, sits buried in that pile. This template moves the whole routine online, so answers arrive before people do and a flagged response is visible the moment it lands.

Ten fields, four of them one-tap answers

The Health Screening Questionnaire runs to 10 fields across a cover page, two content pages, and an ending page. It opens with an identity block: full name and email are required, phone and date of birth are optional, and a gender select offers Male, Female, Non-binary, and Prefer not to say.

The screening core is four required yes or no questions: any symptoms in the past 14 days, recent fever, recent travel, and contact with an infected person. Anyone with something to report can add detail in an optional Current Symptoms box, so a bare Yes never has to stand alone. The whole pass takes 4 to 6 minutes, short enough that most people finish it on a phone before they leave the house.

Who screens with it, and when it earns its keep

Clinics and dental practices send it ahead of appointments so a risk flag surfaces before the patient reaches reception. Employers use it for return-to-work checks and visitor sign-in, care homes run it on families before visits, and schools, camps, and event organizers lean on it whenever a lot of people need clearing through a door in a short window.

The template is built to identify health risks early through symptom screening and risk factor assessment, and every part of it bends to your setting. Rewrite the travel question for your region, drop date of birth if you do not need it, or make the phone field required when staff must be able to call someone back.

From a pile of answers to a clear call

Responses land in Uplup's analytics with a per-question breakdown, so instead of leafing through sheets you can see at a glance how many people answered Yes to recent fever this week, or whether contact exposures are creeping up. When a single response needs action, open it, read the Current Symptoms note, and decide.

For records, export everything to CSV. If a flag needs to reach someone immediately, wire the form to webhooks or Zapier and route new responses into whatever your team already watches.

Reaching people before they reach the door

Send the link inside your appointment confirmation or shift reminder, print the QR code at the entrance for anyone who arrives unscreened, or embed the questionnaire on your site. WordPress sites can drop it in with a shortcode through the Uplup plugin, and your logo and colors keep it looking like yours rather than ours.

The questionnaire is set up for conversational mode, which shows one question at a time. For a screening built around quick yes or no calls, that pacing works: each question gets a clear answer before the next appears, and nobody skims past the one that mattered.