A clinical intake assessment with a weighted 1–5 scoring engine across five dimensions (symptoms, medical history, risk factors, lifestyle, follow-up needs) that produces a personalized, printable AI PDF report and an AI consultant chat via QR code.
Quick answer
A clinical intake assessment with AI PDF report scores five dimensions (symptoms, history, risk, lifestyle, follow-up), writes a personalized report the patient keeps, and hands them an AI consultant chat via QR code.
Disclaimer: this page and its AI report are for self-reflection and process reference only. They do not constitute medical, psychological, financial, legal or safety advice. Consult a qualified clinician before making care decisions.
Methodology: items are a structural adaptation of widely used clinical frameworks, not an official validated instrument; scores are indicative, not diagnostic.
Every clinical intake form ends the same way — data sits in a chart nobody opens. This assessment turns the same inputs into a personalized, printable AI PDF report: five dimensions (symptoms, history, risk, lifestyle, follow-up) each weighted 1–5, a small radar and per-dimension bars, plus an AI-written interpretation in the patient's own words. A QR on the report hands them an AI consultant chat trained on this topic.
Sample form, AI PDF report and AI consultant — fill the form to unlock all three.
Everything you need to run this template.
From copy to deliverable in four steps.
Copy the form and its scoring, report and branding settings into your FormLM workspace — free.
Adjust fields, options and consent language to match your clinic workflow.
Send the link or QR; every response is captured automatically.
Open the personalized AI PDF report and share it with the patient or the chart.
Pick your role — see how it fits your clinic workflow.
The report is the deliverable — patients walk away with a printable document, not just a consultation.
Score the same five dimensions every review; trends appear automatically.
Hand a printed, personalized report at the end of the assessment.
What makes this template work as a professional clinical deliverable.
A preview of real fields patients see — the full version scores each answer 1–5 across dimensions and generates a personalized, printable AI PDF report per respondent.
