Healthcare & Wellness
Mental Wellbeing Screening
A short, clinically-styled mood and anxiety screener counseling practices can send before a first session — gentle, private, and follow-up strictly opt-in.
- Questions
- 10
- Style
- One page
- Price
- Free
Mental Wellbeing Screening
A short, clinically-styled mood and anxiety screener counseling practices can send before a first session — gentle, private, and follow-up strictly opt-in.
Before you begin
Over the last two weeks, how often have you experienced…*
Overall, how would you rate your mood this week?*
What has been weighing on you most?
Would you like to say what it is?
Do you currently have someone you can talk to about how you feel?*
Would you like someone from the practice to reach out?*
Phone number (optional)
More Healthcare & Wellness templates
Full name*
Full nameDate of birth*
Pick a datePhone number*
Phone numberPatient Intake
A three-page intake — personal and emergency contacts, medical background, then consent and signature.
16 questionsOne question at a time
Patient name*
Patient nameEmail address*
Email addressPhone number*
Phone numberAppointment Booking
Let patients request an appointment with type, preferred slot, and the reason for the visit.
10 questionsOne page
Date of birth*
Pick a dateExisting conditions*
Option oneOption twoTell us the condition
Tell us the conditionMedical History
A structured history — conditions, medications, surgeries, family history, and lifestyle.
9 questionsOne page
DataBoard templates
Start from a good first draft.
Pick the closest template, use it, and publish your own version, changed to fit.