Healthcare Form Field Types

EasyDocForms includes standard form controls plus healthcare-specific field types for clinical intake, consent, insurance, pain documentation, medication capture, and specialty workflows.

Standard Fields

Use standard fields for everyday form questions:

Field	Common healthcare use
Text	Names, MRN, short answers, provider names.
Comment	Symptoms, history, free-text explanations.
Radio group	One answer, such as yes/no or sex at birth.
Checkbox	Single acknowledgment or consent checkbox.
Checkbox group	Multi-select symptoms, conditions, allergies, or preferences.
Dropdown	State, location, provider, service, or predefined option lists.
Matrix	Repeated rating scales and structured rows.
Matrix dynamic	Repeating card-based entries, such as injury history or medications when a custom field is not needed.
Panel dynamic	Repeatable grouped sections with a patient-friendly yes/no gate.

Patient Demographics

The patient demographics field captures structured patient identity and contact fields:

• First name.
• Last name.
• Date of birth.
• Calculated age.
• Sex.
• Address.
• City.
• State.
• ZIP code.
• Phone.
• Email.

Use this field when you want responses to link cleanly to Patient Profiles.

Date of Birth and Today's Date

Use Date of Birth when the form needs a DOB and optional age calculation. Use Today's Date when the form must stamp the completion or signing date into the patient response.

Body Pain Diagram

The body pain diagram lets patients mark areas where they experience pain. This is useful for:

• Chiropractic intake.
• Physical therapy intake.
• Orthopedic intake.
• Pain management.
• Personal injury and workers' compensation.
• Neurologic or musculoskeletal screening.

The response data can be rendered into generated PDFs so the clinical team sees the marked areas with the intake record.

Body Diagram 2 / Sensation Diagram

The second body diagram is used for sensation-type markings rather than only pain. It can support workflows where patients need to mark numbness, tingling, burning, weakness, or other sensation categories.

Review of Systems

The review-of-systems field walks the patient through body systems in a structured sequence. It covers categories such as:

• General or constitutional.
• Skin.
• Neurological.
• Eyes.
• Ears.
• Nose and sinus.
• Mouth and throat.
• Heart and lungs.
• Breasts.
• Stomach and GI.
• Genitourinary or reproductive.
• Endocrine or glandular.
• Psychiatric or mental.
• Hematologic or lymphatic.

Use this when the clinic needs a broad medical symptom inventory without a dense paper-style checklist.

Medication List

The medication list field asks whether the patient takes medications or supplements, then allows manual entry or image-assisted extraction. It stores structured medication rows with fields such as medication name, dosage, form, and frequency.

Image capture is used to extract medication information. The form stores extracted medication data, not the original image as a permanent medication photo record.

Medication Barcode

Medication barcode capture can record package barcode details such as:

• Medication name.
• GTIN.
• Lot number.
• Expiration date.
• Raw barcode.
• Symbology.
• Scanned timestamp.

Use this for workflows that need package-level medication or inventory context.

Insurance Card Capture

Insurance card capture lets patients upload card images and extracts structured fields such as:

• Member ID.
• Member name.
• Group number.
• Issuer name.
• Plan type.
• Rx BIN.
• Rx PCN.
• Rx group.
• Copays.
• Deductible.
• Out-of-pocket maximum.

Staff should review extracted insurance details before billing, eligibility checks, or clinical decisions.

Surgery List

The surgery list field asks whether the patient has had prior surgeries and stores structured entries with description and year.

Imaging List

The imaging list field records imaging history, such as type, body part, date, and findings. It is useful for orthopedic, chiropractic, pain, and rehab workflows.

Physician Share

Physician share helps patients provide medical information they want a clinician to review, such as lab results, imaging reports, notes, or other documents. AI can summarize key information, but staff should review summaries before relying on them.

Medicare ABN

The Medicare ABN field supports Advance Beneficiary Notice workflows for Original Medicare situations where Medicare payment may be denied. See Medicare ABN Forms.

ADL Assessment

The Activities of Daily Living assessment collects activity limitations across physical, functional, travel, and recreational activities. It calculates scores and severity labels for intake and documentation.

Consent Document

The consent document field supports multi-section consent text, patient initials, patient signature, clinician signature, witness signature, acceptance checkbox, printed name, and date settings. See Consent Documents and Signatures.

Choosing the Right Field

Goal	Recommended field
Collect patient identity	Patient demographics
Capture DOB and age	Date of birth
Mark pain locations	Body pain diagram
Mark numbness or sensation	Body Diagram 2
Capture broad symptoms	Review of systems
Collect medications	Medication list
Scan package-level medication info	Medication barcode
Collect insurance details	Insurance card capture
Collect surgery history	Surgery list
Collect imaging history	Imaging list
Collect ABN beneficiary choice	Medicare ABN
Collect consent signatures	Consent document
Collect functional limitation scores	ADL assessment

Specialty Field Combinations

Different medical offices can combine the same field types in different ways:

• Chiropractic intake often uses demographics, body pain diagrams, review of systems, imaging history, insurance card capture, and consent.
• Physical therapy intake often uses body-region questions, ADL assessment, surgery history, imaging history, and consent.
• Pain management intake often uses pain diagrams, medication lists, imaging history, prior procedure history, and procedure-specific consent.
• Orthopedic intake often uses injury mechanism questions, body-region complaints, imaging history, surgery history, medication lists, and generated PDFs.
• Podiatry intake often uses foot and ankle complaint questions, pain or sensation diagrams, diabetic foot screening, wound screening, medication lists, and consent.
• Acupuncture intake often uses pain diagrams, review of systems, medication and supplement history, consent, and follow-up symptom updates.
• Med spa and aesthetic workflows often use medical screening, medication history, treatment-specific consent, and clinician countersignature.
• IV therapy workflows often use medical screening, medication and allergy questions, contraindication checks, IV treatment consent, and medication barcode scanning in the iOS note workflow.