Medical Appointment Intake

This is an SmarkForm demonstration page.

This example models a patient intake form for a medical appointment, capturing personal details, medical history, current medications, allergies, and the reason for the visit.

Complete documentation at https://smarkform.bitifet.net.
Latest version and more examples at https://smarkform.bitifet.net/resources/examples
GitHub: https://github.com/bitifet/SmarkForm.
NPM: https://www.npmjs.com/package/smarkform.
Background image courtesy of Lorem Picsum

Patient Information

First Name

Last Name

Date of Birth

Sex

Phone

Address

Emergency Contact

Name

Relationship

Phone

Current Medications

💊

Allergies

⚠️

Medical History

Do you have any chronic conditions? Yes No

Known Conditions

Previous Surgeries or Hospitalizations

Reason for Visit

Chief Complaint

Symptoms Since

Pain Level (0–10)

Additional Notes