This page will guide you through how you can add different controls to create a form.

Patient Demographics and Clinical History Form

Here is an example of a form that can be linked to any collection protocol.

Patient Demographics and Clinical History Form

A. Demographics Information

Health Card #
Chart Number

B. Social History

Do you exercise? How often?
Do you smoke? How often?
Do you drink? How often?
Do you take drugs? How often?

C. Physical Exam Findings

HT: WT: BMI: Heart Rate:

D. Clinical Data (SubForm)

Please select if you have ever diagnosed with any of the following conditions:

Thyroid
Arthritis
Lupus
Breast cancer
Ovarian Cancer
Genetic Abnormalities
Sexually Transmitted Diseases (STDs)
Abdominal Pain

Any medication that are taking for each diagnosis?

Upload health records

E. Past Medical History

Please explain if you had any previous surgery?

Please explain if you had any medical illnesses or psychiatric conditions?

Please Mark if you have allergies to any of the following options? Mark all that applies

Nuts

Iodine

Latex

F. Record of the date and personnel who filled out the form

Create

Refer 'Create' section of the wiki page to create a form.

Add Fields

Create a custom form, 'Patient Demographics and Clinical History' as mentioned above. Refer 'Add Controls' section of the wiki page for adding different controls.

OpenSpecimen

Sample Forms

Patient Demographics and Clinical History Form

Create

Add Fields