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Sample فرم پذیرش بیمار

مشخصات، سابقه‌ی پزشکی، داروها، حساسیت و بیمه — پیش از ویزیت اول.

13 questions · Free up to 50 responses a month

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About this template

“فرم پذیرش بیمار” has 13 questions on 2 pages; 7 are required and 6 optional. Question types: Short text (2), Mobile number (2), Long text (2), National ID (1), Date (1), Single choice (1), Dropdown (1), Multiple choice (1), Yes / No (1), Accept the terms (1). Its sections, in order: «مشخصات», «سابقه‌ی پزشکی». 13 ready-made options across 3 choice questions, all editable in the online version.

In the online version of this template

  • National IDs are checked instantly with the check-digit algorithm.
  • Mobile numbers are validated against the Iranian number format.
  • Dates are picked and stored on the Jalali (Persian) calendar.
Related:Online form builderIranian national ID validator

مشخصات

  1. 1.

    نام و نام خانوادگی *

    (Short text)
  2. 2.

    شماره موبایل *

    (Mobile number)
  3. 3.

    کد ملی *

    (National ID)
  4. 4.

    تاریخ تولد *

    (Date)
  5. 5.

    جنسیت

    (Single choice)
    • زن
    • مرد
  6. 6.

    بیمه

    (Dropdown)
    • تأمین اجتماعی
    • سلامت
    • نیروهای مسلح
    • تکمیلی
    • آزاد
  7. 7.

    تماس اضطراری

    (Mobile number)

سابقه‌ی پزشکی

  1. 8.

    بیماری زمینه‌ای

    (Multiple choice)
    • دیابت
    • فشار خون
    • قلبی
    • آسم
    • تیروئید
    • هیچ
  2. 9.

    داروهای مصرفی

    (Long text)
  3. 10.

    حساسیت دارویی دارید؟ *

    (Yes / No)
  4. 11.

    به چه دارویی؟

    (Short text)
  5. 12.

    شکایت اصلی امروز *

    (Long text)
  6. 13.

    رضایت درمان و حفظ محرمانگی را می‌پذیرم *

    (Accept the terms)

Printable or online?

Printable version (Word & PDF)

  • For filling in on paper, signing and filing by hand
  • Edit the Word file any way you like
  • Collecting and typing up the answers is up to you
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Online version on Porsino

  • Answers are collected and organised automatically — no retyping
  • National ID, mobile number and dates are validated instantly
  • Ready-made reports and charts, plus Excel export in one click
  • Share a link or QR code — it works on mobile too
Build the online version for free

How do I use this template?

  1. Sign up for Porsino for free; no bank card needed.
  2. In the panel, open “Templates” and choose “فرم پذیرش بیمار”.
  3. Change the questions as you like, publish the form and send the link.

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