About this template
The Pre-Screening Google Form Template provides a streamlined method for healthcare facilities, schools, and offices to collect preliminary health and background information. Whether you are screening visitors, patients, or prospective staff for acute symptoms, travel history, or potential exposures, this form gathers critical health data quickly and securely.
Designed to protect staff, stakeholders, and visitors, this template covers key symptom indicators—such as fever, respiratory changes, and gastrointestinal issues—alongside contact history and travel disclosures. Doc2Form allows you to instantly generate this ready-to-use Google Form, making it effortless to organize responses in a connected spreadsheet for immediate review.
Using a structured pre-screening process eliminates manual guesswork, ensures consistent safety protocols, and provides a documented audit trail for compliance and facility safety. Customize the questions to align with your organization's current guidelines and share the link via email or website embedding in seconds.
Key features
- Collect comprehensive symptom checklists in a single, structured form.
- Streamline intake workflows for visitors, patients, or staff.
- Track international travel history and exposure status effortlessly.
- Instantly connect submissions to Google Sheets for real-time review.
- Fully customizable to match your organization's specific screening criteria.
Use cases
Daily health and symptom checks for healthcare clinic visitors and st…
Daily health and symptom checks for healthcare clinic visitors and staff.
Initial visitor screening for schools, daycares, and educational faci…
Initial visitor screening for schools, daycares, and educational facilities.
Pre-visit health evaluations for telehealth appointments and in-offic…
Pre-visit health evaluations for telehealth appointments and in-office consultations.
Pre-interview health and safety verification for on-site candidates.
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Date of Birth (Date)Select your date of birth.
- Email Address (Short answer)Provide a reliable email address for confirmation and follow-up.
- Experiencing Fever, Chills, or Shaking? (Multiple choice)Select your current status.
- Experiencing Difficulty Breathing or Shortness of Breath? (Multiple choice)Select your current status.
- Experiencing a New or Worsening Cough? (Multiple choice)Select your current status.
- Experiencing a Sore Throat? (Multiple choice)Select your current status.
- Experiencing an Unusual Headache? (Multiple choice)Select your current status.
- Experiencing Muscle Pain or Body Aches? (Multiple choice)Select your current status.
- Experiencing Vomiting or Diarrhea? (Multiple choice)Select your current status.
- Experiencing Recent Loss of Taste or Smell? (Multiple choice)Select your current status.
- International Travel History (Multiple choice)Have you traveled outside the country in the last 14 days?
- Known Exposure (Multiple choice)Have you had close contact with anyone diagnosed with COVID-19 or another contagious illness in the last 14 days?
- Electronic Signature (Short answer)Type your full legal name to certify that the information provided above is accurate and true.
- Date Signed (Date)Select today's date.
FAQ
What is the primary purpose of this pre-screening form?
It is designed to quickly capture essential health status, symptom history, and exposure details from individuals before they enter a facility or attend an in-person appointment.
Can I customize the questions on this Google Form template?
Yes. Once Doc2Form generates your form in Google Drive, you have full control to add, remove, or modify any questions to fit your specific requirements.
How do I review the responses submitted by users?
All submissions automatically populate a Google Sheet linked directly to the form, allowing you to filter, sort, and analyze data in real time.
Can I share this form via a direct link or embed it on my website?
Yes, standard Google Forms generated through Doc2Form can be shared via direct link, emailed to participants, or embedded directly into any web page.
Is this template free to use with Doc2Form?
Doc2Form instantly converts templates into your Google account for free, giving you an editable Google Form ready to distribute immediately.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.