This research intake questionnaire template gives clinical study teams a complete enrollment packet on six printed pages, covering informed consent, demographics, health screening, study schedule preferences, baseline measures, and contact details. Participants complete it at the screening visit, and the coordinator scans the finished forms instead of typing every record by hand.
What this survey measures
The form opens with a study information box, a consent question, and a signature and date line, so agreement to participate is documented before any data is collected. A demographics page records date of birth, gender, education, employment, height, and weight. A ten-row screening grid flags common medical conditions, with space to list current medications and supplements. A discrete choice task compares two study schedules across visit frequency, visit length, and compensation, revealing which arrangement participants actually prefer, while a baseline page captures symptom frequency, quality of life, and average sleep. Contact details and follow-up preferences close the form.
How to use it on paper
Print the questionnaire and hand it to participants on a clipboard at the screening visit. Participants fill the checkboxes and write their answers with a blue or black pen, then sign the consent page. Scan the completed forms in batches: PaperSurvey reads the marks with optical mark recognition and converts handwritten fields to text, so every record lands in your dashboard without manual data entry.
Customize this template
Rename the study, adjust the condition list to match your protocol, edit the attributes in the choice task, or add eligibility questions. The paper layout reflows automatically as you edit, and every printed copy stays scannable.
Preview the PDF above, or use this template to start enrolling participants today.