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Clinical Research Intake Questionnaire Template

Research intake questionnaire template with 50 questions covering consent, demographics, health history, lifestyle, baseline measures, study preferences, reasons for taking part, and contact details.

Questions: 50EnglishResearch and Academia

Print this ready-made questionnaire and hand it out, then scan and upload the completed forms to read the answers automatically. You can also share the same questionnaire online. The preview below shows the paper version.

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This research intake questionnaire template gives clinical study teams a complete enrollment packet on six printed pages, covering informed consent, demographics, health history, lifestyle, baseline measures, study schedule preferences, reasons for taking part, 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 section records date of birth, gender, ethnicity, race, marital status, education, employment, height, and weight. A ten-row screening grid flags common medical conditions, followed by family history, current medications and supplements, allergies, and recent surgery. Lifestyle questions cover tobacco, alcohol, physical activity, exercise, and sleep, and the baseline measures capture general health, symptom frequency, difficulty with daily activities, quality of life, and stress. A discrete choice task compares two study schedules across visit frequency, visit length, and compensation, revealing which arrangement participants actually prefer, alongside availability and travel questions. A short section on taking part asks why the participant wants to join, which parts of the study worry them, and how confident they are about attending every visit. Contact details, follow-up preferences, an emergency contact, and two comment boxes 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.

Paper and web from one template

Use this questionnaire on paper, online, or both, and collect all responses in one place. Open it in a new tab. This is a preview only. Responses are not saved.

Questions in this template

  1. Participant ID (assigned by study staff)
  2. Do you agree to take part in this research study?
  3. Today's date
  4. Participant signature
  5. Date of birth
  6. What is your gender?
  7. Are you of Hispanic or Latino origin?
  8. Which of these best describes your race?
  9. What is your marital status?
  10. What is the highest level of education you have completed?
  11. What is your current employment status?
  12. **Height in inches**
  13. **Weight in pounds**
  14. Have you ever been diagnosed with, or treated for, any of these conditions?
  15. Has a parent, brother or sister ever been diagnosed with any of the following?
  16. Please list all medications and supplements you currently take, including the dose if you know it.
  17. Please list any allergies and describe any surgery or hospital stays in the past five years.
  18. Please indicate whether the following apply to you.
  19. Do you currently smoke or use tobacco products?
  20. How often do you drink alcohol?
  21. How would you describe your usual level of physical activity?
  22. **Days of exercise per week**
  23. **Hours of sleep per night**
  24. In general, how would you rate your health?
  25. In the past four weeks, how often have you experienced the following?
  26. How much difficulty do you have with each of these activities?
  27. Overall, how would you rate your quality of life over the past month?
  28. How stressed have you felt over the past month?
  29. Frequency Visit length Compensation
  30. Which days are you generally available for study visits?
  31. Which times of day suit you best for visits?
  32. How will you usually travel to study visits?
  33. How far do you live from the study site?
  34. Could you complete some study questionnaires online at home?
  35. What are your main reasons for wanting to take part in this study?
  36. How concerned are you about each of the following?
  37. How confident are you that you can attend every scheduled visit?
  38. May we contact you about other studies you may be eligible for in the future?
  39. Phone number
  40. Email address
  41. How would you prefer the study team to contact you?
  42. What is the best time of day to reach you?
  43. May we leave a voicemail or text message if we cannot reach you directly?
  44. How did you first hear about this study?
  45. Would you like to receive a summary of the results when the study ends?
  46. Emergency contact name
  47. Emergency contact relationship to you
  48. Emergency contact phone number
  49. Is there anything else the study team should know before your first visit?
  50. Do you have any questions you would like the study team to answer?

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