Template Product Research Wellness Intake Form Template

Wellness Intake Form Template

Wellness Intake Form Template

Create a survey from a ready-made template in 30 seconds. Choose a template, customize it, then share it and collect responses with ease.
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12
Questions
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Wellness Intake Form Template

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*
1.
Full name
2.
Email address
3.
Phone Number
4.
Please indicate your gender
Male
Female
5.
Date of birth
6.
How did you hear about us?[Checkboxes]
Word of mouth
Website search
Social media
Other media
Other
7.
Which hair and scalp wellness issues describe your main concerns? (Select all that apply)[Checkboxes]
Fine hair
Thinning hair, hair loss
Non or slow growing hair
Damaged hair
Oily scalp
Sensitive scalp
Dandruff
8.
Please specify
9.
Have you used our products in the last 6 months to manage your hair or scalp concerns?
Yes
No
10.
Have you used other hair or scalp treatments within the last 6 months?
Yes
No
11.
Are you interested in volunteering for before-and-after photos?
Yes
No
12.
Would you like to be added to our mailing list to receive information about new products and specials?
Yes
No
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Template instructions
Wellness intake form template helps practitioners collect essential client health and wellbeing information. Use this template to streamline intake for clinics, gyms, spas, yoga studios, or telehealth appointments. Share it via a link or embed it on your website, and collect responses from any device.

The free template includes fields for name, email, date of birth, gender, contact details, referral source, and specific wellness concerns such as scalp and hair issues. It also asks about recent product or treatment use and volunteer consent for before/after photos.

Questions are easily customizable so you can add medical history, preferences, or intake notes. The form supports device-friendly embeds, offline mobile collection, and integrations with cloud storage or CRM tools to securely store responses. You can also enable conditional logic, file uploads, and HIPAA-compliant options for practices that require enhanced privacy settings.

Click "Use This Template" to start customizing and collecting client information instantly.

Get Started in 3 Simple Steps

1

Use This Template

Click "Use This Template" to open it in SurveyMars. You can preview and test it without signing up.

2

Customize Your Survey

Edit questions, upload your logo, and match the design to your brand. Create professional surveys with no technical skills required.

3

Share & Collect Responses

Share by link, QR code, or embed it on your website. Responses appear in your dashboard as soon as they come in.

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