Patient Intake Access
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Patient Intake Questionnaire
Women's Health · Ages 35–65
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Prototype notice: this build is a UX/content prototype for review. It is not yet connected to an encrypted clinical intake service and must not be used to submit real protected health information.
Before you begin: This questionnaire helps your care team build a complete picture of your health. Tap the ? icon next to any question if you're unsure what it means. If a question doesn't apply, or you genuinely don't know the answer, choose "Not sure" or "Prefer not to answer" rather than guessing — an unclear answer tells your care team to follow up, it is never treated as "no."
Section A
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Enrollment, Goals & Contact
A01What would you most like help with through your healthcare provider? (check all that apply)
This helps your care team focus on what matters most to you, not just what shows up on a checklist.
A02What health concern is most important to address first?
A03Preferred name and preferred language
A04Preferred and safe contact methods and times
If it isn't safe for someone else to see messages or calls from us, please tell us here — we'll work around it.
Patient portal messages will use your existing portal account on file.
A05Do you have any other clinicians involved in your care (PCP, OB-GYN, or other specialists)?
List anyone currently involved in your care so we can coordinate rather than duplicate.
A06For OB-GYN care, would you like to:
A07Insurance confirmation (optional for this PoC)
In production, insurance information will come from the health system's EHR or registration system. Enter updates here only if needed for testing.
Section B
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Demographics & Anatomy
B01Date of birth
PACE eligibility requires the patient to be between ages 35 and 65.
B02How would you describe your race, ethnicity, ancestry, or country/community of origin?
This is used to provide context for genetics and equity research only — it does not by itself change any recommendation without documented, validated clinical justification.
B04Which of the following organs do you currently have? (your best knowledge is fine)
This affects which screenings and questions apply to you — for example, someone without a cervix doesn't need cervical cancer screening. Please answer for all four.
B05You indicated one or more organs are absent or uncertain — have you had any surgeries or procedures involving these organs?
B06Could you be pregnant right now?
B07Are you hoping to become pregnant, now or in the future?
Section C
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Medical, Family History & Medicines
C01Do you have any current or past significant medical conditions?
C02Have you had any hospital stays, emergency visits, surgeries, or other facility care?
C03Do you have any allergies or medication intolerances?
C04Are you currently taking any prescription or over-the-counter medicines?
C05Do you take any vitamins, supplements, or herbal products?
C06Does anyone in your immediate or close family have any significant medical conditions?
Include relation, side of family (maternal/paternal), condition, and age at diagnosis, death, or event if known.
C07Has anyone in your family had genetic testing, or do you know of a genetic variant (like BRCA) in your family?
Section D
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Lifestyle & General Health
D01Do you currently use, or have you ever used, tobacco or nicotine products?
Product type
Frequency / amount
Total years of use
If former user: when did you quit?
D02Physical activity, including weight-bearing or resistance activity
Weight-bearing exercise (walking, running, resistance training) specifically supports bone density, separate from overall activity level.
D03How would you describe your typical eating pattern, and do you have reliable access to healthy food?
D04Weight, height, and waist circumference (your best current estimate)
This will be verified at your visit — your best estimate is fine for now.
D05Sleep — duration, quality, and any concerns
D06Do you have any of the following? (check all that apply)
D07Are there any current symptoms you're experiencing that haven't been asked about elsewhere in this form?
Section E
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Reproductive Health, Menopause & OB-GYN
E01How old were you when you got your first period?
E02What is your current menstrual/menopausal status?
Approx. date of last period, if known
E03Have you ever been pregnant?
Answering this lets us skip the pregnancy-specific questions below if they don't apply to you.
E04Pregnancy history
E05Have you had any of the following during a pregnancy?
E06Have you experienced infertility, IVF, or other fertility treatment?
E07Current and past hormonal contraception
This is about contraception specifically — hormone replacement therapy for menopause is asked separately below.
E08Menopausal hormone therapy (HRT)
This is different from birth control — HRT is used to manage menopause symptoms, not for contraception, even though it may contain similar hormones.
Components (check all that apply)
E09Hot flashes or night sweats
E10Vaginal dryness, pain with intercourse, urinary urgency, or recurrent UTIs
E11If you have a uterus/cervix: how would you describe your bleeding pattern?
E12Do you have pelvic pain?
Pattern (check all that apply)
E13Have you ever had fibroids, ovarian cysts, endometriosis, or a related gynecologic procedure?
E14Bladder leakage, blood in urine, or pelvic pressure/bulging (prolapse)
E15Do you have a history of sexually transmitted infections, or a current concern?
Section F
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Cardiovascular Health
F01Have you ever had a heart attack, stroke, TIA, heart failure, or other diagnosed heart/vascular condition?
F02Have you been diagnosed with high blood pressure?
Most recent reading, if known
F03Have you had a lipid panel (cholesterol test) done?
A lipid panel measures LDL ("bad" cholesterol), HDL ("good" cholesterol), and triglycerides. A statin is a cholesterol-lowering medication (e.g., Lipitor, Crestor). Lp(a) is a less commonly ordered, largely genetic marker.
F04Are you currently having chest discomfort, breathlessness, fainting, focal neurologic symptoms, or exercise intolerance?
F05Do you experience heart palpitations (racing, pounding, or fluttering heartbeat)?
F06Do you get migraine headaches? If so, with or without aura (visual disturbances/warning signs)?
F07Do you have an autoimmune or inflammatory condition, or use anti-inflammatory medications (NSAIDs) regularly?
F08If you've had breast cancer treatment, did it include chemotherapy or radiation near the heart?
Section G
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Bone Health
G01Have you had any fracture as an adult that wasn't from major trauma (like a car accident)?
G02Has either of your parents ever had a hip fracture?
This is a specific, validated predictor of your own fracture risk.
G03Have you used steroid medications (glucocorticoids) for 3 months or longer?
G04Do you have rheumatoid arthritis, hyperthyroidism, a malabsorption condition (e.g., celiac), liver/kidney disease, or type 1 diabetes?
These conditions are linked to secondary osteoporosis, so we ask about them specifically for bone health, even though some may already be in your medical history above.
G05Have you had any falls in the past 12 months?
G05aDo you use a cane, walker, or other mobility aid?
G06Calcium-rich food intake and Vitamin D history
G07Have you ever had a bone density scan (DEXA)?
Section H
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Colorectal Health
H01Have you personally been diagnosed with colorectal cancer?
H02Have you ever undergone routine colorectal cancer screening when you did not have symptoms or a known colorectal cancer diagnosis?
Routine screening is different from testing performed because of symptoms or an existing cancer diagnosis.
H02aHave you personally had colorectal polyps found during screening or another procedure?
H03Do you have a family history of Lynch syndrome, FAP, or colorectal cancer?
This is captured in more detail in your family history above (Section C) — this question just confirms whether it applies.
H04Have you been diagnosed with ulcerative colitis, Crohn's disease, or primary sclerosing cholangitis?
H05Have you had radiation therapy to your abdomen or pelvis?
H06Do you currently have any of the following?
Section I
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Breast Health
I01Have you personally been diagnosed with or treated for breast cancer or DCIS?
I02Do you currently have a new or persistent breast or underarm lump, pain, or nipple discharge?
This asks about anything you're noticing right now — it's followed up on regardless of your last mammogram result.
I03Has anyone in your family had breast or ovarian cancer?
Detailed relation, cancer type, and age are captured in your family history (Section C) — this confirms whether it applies to breast/ovarian specifically.
I04Known family BRCA1/2 or other genetic variant, even if you haven't been tested yourself?
I05Have you had a breast biopsy showing atypia, LCIS, ALH, or ADH?
I06Did you have chest radiation therapy between ages 10 and 30?
I07Your most recent breast imaging (mammogram, ultrasound, or MRI)
Modality (check all that apply if you've had more than one recently)
I08Have you ever had a formal breast cancer risk assessment (like Tyrer-Cuzick), or been told you're high risk?
Section J
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Hormonal & Metabolic Health
J01Do you have any history of diabetes, prediabetes, insulin resistance, or gestational diabetes? (check all that apply)
J02Have you been diagnosed with PCOS, or had irregular periods, ovulation problems, excess hair growth, or acne beyond your teens?
J03Do you personally have a history of thyroid disease, nodules, thyroid surgery/radiation, or postpartum thyroiditis?
Type (check all that apply)
J03aDoes anyone in your family have a history of thyroid disease?
Detailed relation and condition are captured in your family history (Section C) — this confirms whether it applies to thyroid specifically.
J04Have you recently experienced any of the following?
J05Have you had recent A1C, glucose, or other metabolic testing?
J06Are you currently taking a statin, thiazide diuretic, or certain HIV medications? (medications linked to metabolic risk)
Section K
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Behavioral Health & Substance Use
Are you alone, using a safe/private device, and comfortable answering the standardized behavioral-health screening questions right now?
If you select No / not right now or skip, the standardized screening questions will not be required. The remaining behavioral-health history questions below are still part of this intake and may be answered without completing the screening instruments.
PHQ-9. Over the last 2 weeks, how often have you been bothered by any of the following problems?
If your answer to question 9 reflects thoughts of self-harm, please tell your care team directly or contact 988 (Suicide & Crisis Lifeline) by call or text.
GAD-7. Over the last 2 weeks, how often have you been bothered by the following problems? (ages 65+: interpreted with clinical judgment)
PC-PTSD-5 — exposure screen.
K04gHave you ever experienced or witnessed an event that was frightening, horrible, or upsetting — such as a serious accident, assault, combat, or disaster?
PC-PTSD-5. In the past month, have you:
You do not need to describe the event itself unless you want to.
AUDIT-C. Questions about your use of alcohol.
K05Do you use any recreational or non-prescribed drugs?
K06Do you have any current or past behavioral health diagnoses and treatment?
K06aHave you ever been hospitalized for a mental health or substance use reason?
K07aHave you had postpartum depression after any pregnancy?
K07bHave you had postpartum psychosis after any pregnancy?
K07cHave you experienced mood symptoms specifically tied to menopause (perimenopause or postmenopause)?
K08Have you ever experienced an episode of mania or hypomania?
K08aHave you ever experienced an episode of psychosis?
K10If you use tobacco, alcohol, or other substances: are you interested in support to cut back or quit?
Section L
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Social, Safety & Access Needs
L01Have you been worried about not having stable housing?
L02In the past 12 months: were you worried food would run out before you had money to buy more, or did food actually run out?
L03Does a lack of reliable transportation (including getting home) keep you from appointments or daily activities?
L04Has the electric, gas, oil, or water company ever threatened to shut off services?
L05Do you have concerns about affording medications, insurance, or care?
L06Do employment, childcare, caregiving responsibilities, or time off work make it hard to get care?
L07Do you have any needs related to language, literacy, disability accommodation, or access to a computer/internet?
L09Would you like a human coordinator to contact you about any of the needs above?
Section M
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Preventive Care History & Review
M01When was your last primary care / preventive visit?
M02Vaccination history (check all that apply, approximate is fine)
M03Approximate date of your most recent preventive tests, if known
M04Have you had a hospital or ED visit or discharge recently?
M05Are there any records or reports from another provider that your care team should try to obtain?
M06Review your answers
Your responses will be reviewed by your care team before your visit. This does not replace emergency care — if you need help right now, call 911 or go to your nearest emergency room.
Thank you
Your responses have been compiled below. For this PoC, an email draft addressed to contact@svcghealth.com will open on this device. Review it and select Send in your email application.
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