do this
Online Patient Intake Form
  --- Provided by Intake Solutions, Inc. ---

-- by David Swink, 03/30/2017

The dreaded paper Patient Intake form
When a patient comes into a doctor's office, dental office, clinic, hospital emergency room, or laboratory clinic, the patient is given a clipboard with paper form(s) to fill out. In each case, the same rudimentary information is asked, including, name, phone number, address, allergies, medications, SSN, birthdate, age, weight, insurance information, etc, etc. These form(s) are then given to an "intake" person, who either enters the data manually into a similar information data sheet or simply scans the paper form into an image before storing into their computer system. Clearly there is a lot of redundancy and wasted effort.

The patient usually has no historical information at hand, and thus can provide only information that comes immediately to mind -- not to mention that he is required periodically to repeat this effort from scratch. And the medical staff cannot be happy receiving this spontaneous data, which contains so little information of real value.

Enter a web-based alternative!
But what if the specific form was available online, with the patient able to fill out and submit the completed form at home prior to seeing the doctor? Two very different working proof-of-concept forms are provided below, along with snapshots showing progress to completion:
intakeA.pl intakeB.pl Bring up the "Patient Information Form".
intakeA1.html intakeB1.html Provide basic patient identity information as shown.
intakeA2.html intakeB2.html Press the 'Get Prev Info' button to pre-fill the form with any previously-entered data. If data has not been previously entered, proceed to enter your information in the appropriate fields, and provide as much detail as you can, as this will help your doctors provide you with better care. For pre-fill data from previous entries, make changes as necessary.
intakeA3.html intakeB3.html If there is no new information, simply press the 'Report & Save' button to produce the printable "Patient Information Report". If there is new data, you must first enter your Mother's Maiden Name before changes will be saved, with any changes made denoted by '**'. (This requirement allows other people to view your information, but prevents them from changing any of your entries.)
Load via URL Load via URL You may also pre-fill the "Patient Information Form" directly via the URL, by passing the abbreviated patient name and DOB verification data as parameters in the URL. Both the populated form and the report are available for viewing, regardless of whether the patient's data has been encrypted -- using the script as a 'gateway'. (This is a convenient way to notify the patient to update the information.)

How it would work
The above two examples merely demonstrate the possibilities of using online forms for handling patient information. In actual practice:

There is not yet a permanent web site available for this service. It awaits sufficient enthusiasm from practitioners, who are likely using Electronic Medical Reporting (EMR) systems, which may or may not offer similar capabilities.

While a fixed price schedule has not been determined, cost to providers will be quite reasonable. An office of 1-5 doctors might be charged $100 per month for unlimited online access to patient intake information. Larger practices and institutions would be charged proportionally less due to economies of scale.

For patients, the service is free. For those patients that are comfortable using the internet, there is no downside. Just think of how convenient it will be to immediately recall, update, and print your basic patient information anywhere at any time. Even if your medical provider chooses not to participate, you'll never again need to use that dreaded clipboard.

We think our patient intake tools offer a great value for patient and medical personnel alike. We hope you think so too, and will examine whether our product would enhance your practice.

If interested, please contact: David Swink / 703-281-2678 / swinkdb@gmail.com

History: This work started in 2009 under contract with Dr. Jeffrey Greenberg, a West Virginia neurosurgeon. Time and distance considerations caused the effort to come to a standstill. Then EMRs came along and would surely make clipboards obsolete... except that clipboards are still in use! And different EMRs still don't talk to one another. So perhaps a second effort is "just what the doctor ordered".