Prototype

Intake form prototypes

Complete clinical assessments rebuilt from the JotForm masters — multi-step, with conditional questions, stop rules and dynamic medicine names. Prototype only: nothing is saved or sent.

Contraception

Combined Pill (Contraception) AssessmentMicrogynon 30, Rigevidon, Levest, Logynon…
69 questions · 10 steps · dynamic medicine
 Contraceptive Patch, Ring & Injection AssessmentEVRA Patch, NuvaRing, Sayana Press
59 questions · 8 steps · dynamic medicine
 Mini Pill (Progestogen-Only Pill) AssessmentCerelle, Cerazette, Desogestrel, Zelleta…
47 questions · 8 steps · dynamic medicine
 Morning After Pill (Emergency Contraception) AssessmentLevonelle (Levonorgestrel), ellaOne (Ulipristal)
33 questions · 7 steps · dynamic medicine

Digestive Health

Acid Reflux (GORD) AssessmentOmeprazole, Lansoprazole, Esomeprazole, Pantoprazole
26 questions · 6 steps · dynamic medicine
 Haemorrhoids (Piles) AssessmentAnusol, Uniroid HC, Scheriproct
41 questions · 8 steps · dynamic medicine
 IBS Treatment AssessmentAlverine, Mebeverine (Colofac)
15 questions · 4 steps · dynamic medicine

General Health

Cholesterol (Statin) Treatment AssessmentAtorvastatin, Rosuvastatin
21 questions · 6 steps · dynamic medicine
 EMLA Numbing Cream AssessmentEMLA Cream
15 questions · 4 steps
 Ear & Eye Infection Treatment AssessmentOtomize Ear Spray, Betnesol-N Drops
42 questions · 7 steps · dynamic medicine
 Gout Treatment AssessmentColchicine, Naproxen, Allopurinol
20 questions · 6 steps · dynamic medicine
 Melatonin Sleep AssessmentMelatonin 2mg prolonged-release (Circadin)
26 questions · 6 steps
 Migraine Treatment AssessmentSumatriptan, Rizatriptan, Almotriptan, Naratriptan…
29 questions · 6 steps · dynamic medicine
 Neuropathic Pain Treatment AssessmentAmitriptyline, Gabapentin, Pregabalin
23 questions · 6 steps · dynamic medicine
 Overactive Bladder AssessmentBetmiga (Mirabegron), Detrusitol (Tolterodine), Vesicare (Solifenacin), Oxybutynin
49 questions · 8 steps · dynamic medicine
 Stop Smoking Treatment AssessmentNRT (patches/gum/lozenges), Champix (Varenicline), Zyban (Bupropion)
51 questions · 8 steps · dynamic medicine
 Vitamin D Deficiency Treatment AssessmentColecalciferol (Vitamin D3)
15 questions · 5 steps

Hair

Hair Loss (Finasteride) AssessmentFinasteride 1mg
31 questions · 6 steps

Men's Health

Erectile Dysfunction AssessmentSildenafil, Tadalafil, Vardenafil, Spedra (Avanafil)
47 questions · 8 steps · dynamic medicine
 Premature Ejaculation AssessmentPriligy (Dapoxetine)
27 questions · 5 steps
 Testosterone Testing & Treatment AssessmentTestosterone Replacement Therapy
19 questions · 4 steps

Respiratory & Allergy

Asthma & Respiratory Inhaler AssessmentClenil Modulite, Fostair, Symbicort, Seretide…
29 questions · 7 steps · dynamic medicine
 Hay Fever & Allergy AssessmentFexofenadine, Desloratadine, Levocetirizine, Avamys Nasal Spray…
40 questions · 8 steps · dynamic medicine

Sexual Health

Chlamydia Treatment AssessmentDoxycycline, Azithromycin
18 questions · 5 steps · dynamic medicine
 Genital Herpes Treatment AssessmentAciclovir, Valaciclovir, Famciclovir
42 questions · 8 steps · dynamic medicine
 Genital Warts Treatment AssessmentWarticon (Podophyllotoxin), Aldara (Imiquimod)
29 questions · 6 steps · dynamic medicine
 Gonorrhoea Treatment AssessmentCefixime + Azithromycin
17 questions · 5 steps
 PrEP (HIV Prevention) AssessmentPrEP (Tenofovir/Emtricitabine)
20 questions · 5 steps

Skin

Acne Treatment AssessmentBenzoyl Peroxide, Duac Gel, Epiduo, Differin (Adapalene)…
58 questions · 8 steps · dynamic medicine
 Cold Sore & Herpes Treatment AssessmentAciclovir cream, Aciclovir tablets, Valaciclovir, Famciclovir
19 questions · 4 steps · dynamic medicine
 Eczema & Psoriasis Treatment AssessmentHydrocortisone 1%, Eumovate, Betnovate, Elocon…
66 questions · 8 steps · dynamic medicine
 Excessive Sweating (Hyperhidrosis) AssessmentDriclor, Glycopyrronium tablets
18 questions · 4 steps · dynamic medicine
 Fungal Nail Infection AssessmentAmorolfine 5% Nail Lacquer, Loceryl
33 questions · 6 steps · dynamic medicine
 Rosacea Treatment AssessmentEfracea (Doxycycline MR), Skinoren (Azelaic Acid), Finacea (Azelaic Acid), Metronidazole Gel
34 questions · 7 steps · dynamic medicine
 Scabies Treatment AssessmentPermethrin Cream, Malathion Lotion
16 questions · 4 steps · dynamic medicine
 Skin Infection Treatment AssessmentFucidin Cream, Fucidin H, Fucibet, Daktacort
35 questions · 6 steps · dynamic medicine

Travel Health

Malaria Prevention Travel AssessmentMalarone (Atovaquone/Proguanil), Doxycycline
24 questions · 6 steps · dynamic medicine
 Travel & Motion Sickness AssessmentKwells (Hyoscine hydrobromide), Avomine (Promethazine)
15 questions · 4 steps · dynamic medicine

Weight Loss

Weight Loss Treatment — New Patient AssessmentWegovy (Semaglutide), Mounjaro (Tirzepatide), Saxenda (Liraglutide), Mysimba (Naltrexone/Bupropion)…
69 questions · 9 steps · dynamic medicine
 Weight Loss Treatment — Repeat Supply CheckWegovy (Semaglutide), Mounjaro (Tirzepatide)
33 questions · 6 steps · dynamic medicine

Women's Health

Bacterial Vaginosis (BV) AssessmentMetronidazole tablets, Metronidazole vaginal gel, Clindamycin cream, Fluomizin (Dequalinium)
48 questions · 8 steps · dynamic medicine
 Cystitis (UTI) AssessmentTrimethoprim, Nitrofurantoin (MacroBID)
34 questions · 7 steps · dynamic medicine
 Menopause & HRT AssessmentHRT tablets, HRT patches, HRT gel
29 questions · 6 steps · dynamic medicine
 Period Pain AssessmentMefenamic Acid, Naproxen
31 questions · 7 steps · dynamic medicine
 Thrush Treatment AssessmentFluconazole capsule, Canesten pessary/cream, Canesten Duo, Daktarin oral gel
40 questions · 7 steps · dynamic medicine
 Unwanted Facial Hair (Hirsutism) AssessmentVaniqa (Eflornithine)
18 questions · 4 steps