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Ready-made questionnaire templates you can insert into your own questionnaire.

Patient Demographics — FHIR Questionnaire Template

Name, date of birth, sex assigned at birth and contact details for a patient intake form.

Scoring

No scoring — a data-collection fragment.

Questions

  1. First name
  2. Last name
  3. Date of birth
  4. Sex assigned at birth
    • Female
    • Male
    • Unknown
  5. Phone number
  6. Email address
  7. Home address

Source and license

Source: Original wording written for this builder.

License: Original wording written for this builder; covered by the project license (non-commercial use with attribution; commercial use needs written permission). (link)

Provided to save authoring effort, not as medical advice — confirm the scale and its cut-offs for your use case.

Use it

  1. Download the FHIR Questionnaire JSON, or
  2. open the Builder, choose + Add → From template…, search for “Patient Demographics” and insert it. It arrives as one titled group with its calculations wired, and you can keep editing it.

More templates

This material contains content from LOINC (loinc.org). LOINC is copyright © Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the LOINC license.