{"flag":true,"survey":{"guid":"f4cffca1-0ed0-4e8f-8e4e-e2e57d60b470","email":null,"title":"Doctor's Office Pre-appointment Questionnaire ","centerAligned":false,"dirty":false,"createdDate":"2022-01-07T02:03:40.17067","modifiedDate":"2022-01-07T02:03:40.17067","activePageIndex":0,"pages":[{"guid":"e0b0c1b7-631b-49ec-ae55-6003ac4e8551","title":null,"titleDisplay":"[Page 1]","description":null,"centerAligned":false,"dirty":false,"pageIndex":0,"activeQuestionIndex":5,"deleted":false,"deletedDate":null,"questions":[{"guid":"a484ecc3-0c64-4d90-9a99-1929fd826f0f","questionType":"Textbox List","title":"Patient name:","titleDisplay":"Patient name:","question":"{\"title\":\"Patient name:\",\"elements\":[{\"type\":\"Label 1\",\"label\":\"First\",\"required\":true},{\"type\":\"Label 2\",\"label\":\"Last\",\"required\":true}],\"requireAnswer\":true}","questionIndex":0,"dirty":false,"deleted":false,"deletedDate":null},{"guid":"bf076eb4-30c1-4ab5-b60e-a99d4a096093","questionType":"Date / Time","title":"Patient date of birth:","titleDisplay":"Patient date of birth:","question":"{\"title\":\"Patient date of birth:\",\"requireAnswer\":true,\"collectDate\":true,\"collectTime\":false}","questionIndex":1,"dirty":false,"deleted":false,"deletedDate":null},{"guid":"6393bd44-b840-4c12-8f5b-2e3d640a25a0","questionType":"Multiple Choice","title":"Have you had cough or fever in the past 2 weeks?","titleDisplay":"Have you had cough or fever in the past 2 weeks?","question":"{\"title\":\"Have you had cough or fever in the past 2 weeks?\",\"multiSelect\":false,\"choices\":[\"Yes\",\"No\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"addNoneOfAboveOption\":false,\"addNoneOfAboveLabel\":\"\",\"allowAdditionalCommentsOption\":false,\"allowAdditionalCommentsLabel\":\"\",\"requireAnswer\":true}","questionIndex":2,"dirty":false,"deleted":false,"deletedDate":null},{"guid":"2109e8e2-dfcd-47dd-a129-37bcf9e13eee","questionType":"Multiple Choice","title":"Have you been exposed to anyone in the past 2 weeks with fever or cough?","titleDisplay":"Have you been exposed to anyone in the past 2 weeks with fever or cough?","question":"{\"title\":\"Have you been exposed to anyone in the past 2 weeks with fever or cough?\",\"multiSelect\":false,\"choices\":[\"Yes\",\"No\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"addNoneOfAboveOption\":false,\"addNoneOfAboveLabel\":\"\",\"allowAdditionalCommentsOption\":false,\"allowAdditionalCommentsLabel\":\"\",\"requireAnswer\":true}","questionIndex":3,"dirty":false,"deleted":false,"deletedDate":null},{"guid":"aa0db2f5-a613-4c28-965a-3bf5a21c6279","questionType":"Textbox List","title":"Emergency contact's name and phone number:","titleDisplay":"Emergency contact's name and phone number:","question":"{\"title\":\"Emergency contact's name and phone number:\",\"elements\":[{\"type\":\"Label 1\",\"label\":\"First\",\"required\":true},{\"type\":\"Label 2\",\"label\":\"Last\",\"required\":true},{\"type\":\"Label 3\",\"label\":\"Phone\",\"required\":true}],\"requireAnswer\":true}","questionIndex":4,"dirty":false,"deleted":false,"deletedDate":null},{"guid":"b0ae6f2c-61f9-4edb-9e35-d588ec455978","questionType":"Multiple Choice","title":"Any health problems or concerns?","titleDisplay":"Any health problems or concerns?","question":"{\"title\":\"Any health problems or concerns?\",\"multiSelect\":false,\"choices\":[\"Yes\",\"No\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"addNoneOfAboveOption\":false,\"addNoneOfAboveLabel\":\"\",\"allowAdditionalCommentsOption\":true,\"allowAdditionalCommentsLabel\":\"Please list your health problems or concerns if any.\",\"requireAnswer\":true}","questionIndex":5,"dirty":false,"deleted":false,"deletedDate":null},{"guid":"dcf6d9d8-388e-4643-a0c6-9b2e043be839","questionType":"Multiple Choice","title":"Any medical changes since last visit?","titleDisplay":"Any medical changes since last visit?","question":"{\"title\":\"Any medical changes since last visit?\",\"multiSelect\":false,\"choices\":[\"Yes\",\"No\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"addNoneOfAboveOption\":false,\"addNoneOfAboveLabel\":\"\",\"allowAdditionalCommentsOption\":true,\"allowAdditionalCommentsLabel\":\"Please explain medical changes if any.\",\"requireAnswer\":true}","questionIndex":6,"dirty":false,"deleted":false,"deletedDate":null},{"guid":"1dc23268-6044-44dc-b69a-713beb6dfc7c","questionType":"Multiple Choice","title":"Any recent hospitalizations?","titleDisplay":"Any recent hospitalizations?","question":"{\"title\":\"Any recent hospitalizations?\",\"multiSelect\":false,\"choices\":[\"Yes\",\"No\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"addNoneOfAboveOption\":false,\"addNoneOfAboveLabel\":\"\",\"allowAdditionalCommentsOption\":true,\"allowAdditionalCommentsLabel\":\"Please describe the reasons of your hospitalization if any.\",\"requireAnswer\":true}","questionIndex":7,"dirty":false,"deleted":false,"deletedDate":null},{"guid":"1e0bec2b-9074-4f4a-a0b0-f5b056e38f61","questionType":"Multiple Choice","title":"Any medications?","titleDisplay":"Any medications?","question":"{\"title\":\"Any medications?\",\"multiSelect\":false,\"choices\":[\"Yes\",\"No\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"addNoneOfAboveOption\":false,\"addNoneOfAboveLabel\":\"\",\"allowAdditionalCommentsOption\":true,\"allowAdditionalCommentsLabel\":\"Please list your medications?\",\"requireAnswer\":true}","questionIndex":8,"dirty":false,"deleted":false,"deletedDate":null},{"guid":"e110a497-f792-439b-894f-c351af35dc2b","questionType":"Multiple Choice","title":"Change of address?","titleDisplay":"Change of address?","question":"{\"title\":\"Change of address?\",\"multiSelect\":false,\"choices\":[\"Yes\",\"No\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"addNoneOfAboveOption\":false,\"addNoneOfAboveLabel\":\"\",\"allowAdditionalCommentsOption\":false,\"allowAdditionalCommentsLabel\":\"\",\"requireAnswer\":true}","questionIndex":9,"dirty":false,"deleted":false,"deletedDate":null},{"guid":"f40afa73-5bc3-49fb-a582-c847c0b832cb","questionType":"Multiple Choice","title":"Insurance change?","titleDisplay":"Insurance change?","question":"{\"title\":\"Insurance change?\",\"multiSelect\":false,\"choices\":[\"Yes\",\"No\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"addNoneOfAboveOption\":false,\"addNoneOfAboveLabel\":\"\",\"allowAdditionalCommentsOption\":false,\"allowAdditionalCommentsLabel\":\"\",\"requireAnswer\":true}","questionIndex":10,"dirty":false,"deleted":false,"deletedDate":null}]}],"colorTheme":{"id":160,"guid":"f34e29a6-6c4f-4209-824d-e1992392eed3","name":"Pantone 2020: Classic Blue","isSystem":true,"dirty":false,"accountId":null,"usedCount":0,"profile":{"logoBackColor":"#efefef","titleBackColor":"#2c7dc7","titleTextColor":"#ffffff","pageTitleBackColor":"#60b1db","pageTitleTextColor":"#ffffff","backColor":"#d7f7f9","backImage":"","backIcon":"","backSize":"","backSource":"upload","pageBackColor":"#ffffff","pageDescriptionTextColor":"#000000","validationTextColor":"#ff0000","questionPrefixTextColor":"#ff0000","questionTitleTextColor":"#000000","questionFontWeight":"300","questionTextItalic":false,"questionTextUnderline":false,"answerFontWeight":"300","answerTextItalic":false,"answerTextUnderline":false,"answerTextColor":"#000000","font":"Montserrat"}},"profile":{"language":{"defaultLanguage":"En"},"display":{"surveyTitleOn":true,"pageTitlesOn":true,"pageNumbersOn":false,"questionNumbersOn":true,"requiredAsterisksOn":true,"previousButtonsOn":true,"progressBar":{"on":false,"position":null,"type":"question"},"exitLinkOn":false,"displayFormat":"classic","backgroundOpacity":1.0,"multiChoiceSymbolType":"classic","textboxStyle":"line","watermark":{"url":null,"position":null,"width":null,"height":null,"opacity":0.0}},"footer":{"removeBrandFooter":false,"customFooter":""},"alerts":{"enableDailyAlerts":true,"enableEveryResponseAlerts":false},"logo":{"place":"none","align":null,"url":null,"source":null,"width":null,"height":null},"choiceRnd":{"type":"off","scope":"all","questions":[],"exceptLast":[]},"questionRnd":{"type":"off","scope":"all","questions":[]},"pageRnd":{"type":"off","scope":"all","pages":[]},"buttons":{"previous":null,"next":null,"done":null},"messages":{"invalidAnswer":null,"requiredAnswer":null,"finish":null,"disqualification":null,"closed":null,"alreadyTaken":null,"quotaReached":null},"endPages":{"thankYouRedirectionSeconds":null,"thankYouRedirectUrl":null,"thankYouRecipientEmail":null,"thankYouRecipientCc":null,"thankYouEmailSubject":null,"thankYouEmailBody":null,"disqualificationRedirectionSeconds":null,"disqualificationRedirectUrl":null,"alreadyTakenRedirectionSeconds":null,"alreadyTakenRedirectUrl":null,"closedRedirectionSeconds":null,"closedRedirectUrl":null,"quotaReachedRedirectionSeconds":null,"quotaReachedRedirectUrl":null},"variables":[],"integration":{"salesforceRefreshToken":null,"salesforceOn":false,"googleAnalyticsTrackingCode":null,"salesforceConnects":[],"hubspotRefreshToken":null,"hubspotOn":false,"hubspotConnects":[]},"quota":null,"quotaReached":false,"hasIntroPage":false,"requestedAppraisal":false,"autoSave":false,"autoFill":false,"sentMails":[]},"rules":[],"canManageDesign":false,"canViewDesign":false,"canManageSend":false,"canViewSend":false,"canManageAnalyze":false,"canViewAnalyze":false,"isShared":false,"questionCount":11,"responseCount":0,"collaboratorCount":0,"collectorCount":0,"lastResponseOn":null,"isSample":false,"closed":false},"title":"Doctor's Office Pre-appointment Questionnaire","content":null,"industries":["Healthcare/Medical/Pharmaceuticals"]}
 
 
Not at all likely Extremely likely
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 100
/ /
:
 
 
or drag and drop file here drop file here!

Free Survey Template