Long COVID Clinic New Patient Intake Form

Long COVID Clinic New Patient Intake Form

Living with persistent symptoms after COVID-19 can be challenging and isolating. If you're experiencing ongoing health issues weeks or months after your initial infection, you're not alone—and specialized care can make a real difference.

This Long COVID Clinic New Patient Intake Form is designed for healthcare providers treating patients with post-acute sequelae of SARS-CoV-2 infection (PASC), commonly known as Long COVID. The form captures essential information about infection history, symptom progression, functional limitations, and rehabilitation needs to help clinicians develop personalized treatment plans.

Why Paperform for Long COVID patient intake?

Long COVID patients often struggle with fatigue, brain fog, and physical limitations that make lengthy paperwork exhausting. Paperform creates a patient-centered experience with:

• Clear, accessible design that reduces cognitive load for patients experiencing brain fog
• Save and resume functionality so patients can complete the form at their own pace
• Conditional logic that shows relevant questions based on symptoms, avoiding unnecessary sections
• Mobile-friendly interface for patients who find it difficult to sit at a computer
• Secure data handling with SOC 2 Type II compliance to protect sensitive health information

Streamline your Long COVID clinic workflow

For healthcare providers, multidisciplinary teams, and rehabilitation specialists, this template integrates seamlessly into your existing systems. Submissions can automatically sync to your EHR, trigger appointment confirmations, and route to the appropriate specialists based on symptom presentation.

Need to collect additional documentation or consent forms? Use Papersign (papersign.com) to send treatment consent forms, HIPAA authorizations, or specialist referral documents for eSignature immediately after intake submission—keeping everything connected and organized.

Want to automate your triage process? Connect this form to Stepper (stepper.io) to automatically categorize patients by symptom severity, assign to appropriate care team members, schedule follow-up assessments, and update your patient management system—all without manual data entry.

This template includes sections for demographic information, COVID-19 infection timeline, comprehensive symptom assessment across body systems, functional impairment evaluation, mental health screening, vaccination history, and rehabilitation goals. Whether you're running a dedicated Long COVID clinic, a post-viral syndrome program, or integrating Long COVID care into your existing practice, this form provides the foundation for thorough, compassionate patient assessment.

Start with this template and customize it to match your clinic's specific protocols, add your branding, and connect it to your healthcare workflows—all without writing a single line of code.