MegaForm template demo

Wellness & Patient Intake

A calm, soft multi-step wellness / patient intake form. Fully editable in MegaForm Builder. Centered single-column card with a top dot-progress stepper. Mint-white shell, emerald accent, pill-shaped inputs.

Source: MegaForm_01.07.113_Install.zip / wellness-patient-intake.json
Category: Health
Fields: 27
Theme: system

Verdant Health

Patient Intake

A few gentle questions so we can care for you better. Takes about 3 minutes.

Step 1 of 4

Let’s start with the basics

Tell us a little about yourself so we can prepare for your visit.

Full Name *

Date of Birth *

Biological Sex

Email Address *

Phone Number

Step 2 of 4

Your health background

This helps your practitioner understand your history. All information stays confidential.

Primary Concern *

How long have you had this concern?

Existing Conditions

Current Medications

Known Allergies

Step 3 of 4

A little about your lifestyle

Daily habits give us helpful context for your personalised plan.

Activity Level *

Sedentary (little to no exercise)Light (1–2 days/week)Moderate (3–4 days/week)Active (5+ days/week)

Average Hours of Sleep per Night

Dietary Preference

Smoking Status

Never smokedFormer smokerCurrent smoker

Current Stress Level

Step 4 of 4

Book & confirm

Choose a time that works for you and review the consent details before submitting.

Preferred Appointment Date *

Preferred Time *

Practitioner Preference

Anything else we should know?