Clinical research coordinators
Collect answers in a consistent structure, so you can compare responses while keeping each person’s explanation in context. Review “Date of Birth” in particular and adapt it to the detail you need.
Clinical Trial Screening Form Template
Streamline participant recruitment for your clinical trial with a structured eligibility screening form. This template collects demographics, current medications, inclusion and exclusion criteria confirmations, and contact consent — giving your study coordinator everything needed to pre-screen applicants before scheduling an in-person visit.
Free for non-commercial projects, with unlimited forms and responses.
Last updated
About this template
Clinical trial recruitment is one of the most resource-intensive parts of running any study. Phone pre-screens take 15–30 minutes per applicant, and many callers are immediately disqualified by a single exclusion criterion. A digital screening form solves this by letting applicants self-select through basic inclusion and exclusion criteria before the research team invests any staff time — dramatically improving the efficiency of your recruitment funnel.
More about this template
This template covers the core fields that matter at the initial screen: demographics for population tracking, medical history for contraindication flagging, criteria confirmation checkboxes, and explicit contact consent. The inclusion and exclusion criteria sections use checkbox fields so applicants clearly affirm each item — making your pre-screen documentation stronger if questions arise later in the study.
formformform's unlimited submission model is especially well-suited for trials with large recruitment targets. Whether you're screening 50 applicants or 5,000, the form handles the volume without per-submission charges, and every entry is timestamped and stored securely for your records coordinator to review.
14 fields to make your own12 required in this starting form
Make it fit your workflow.
Use your own copy to change labels, remove questions and add the details you need. Try the preview alongside this guide to see what respondents will be asked.
The questions, explained
Fields in this template
Review the starting questions and choices. You can change them in your own copy.
Full Name
Jane Smith
Email Address
your@email.com
Phone Number
(555) 123-4567
Date of Birth
Gender
5 choices
- Male
- Female
- Non-binary
- Prefer not to say
- Other
Height (cm)
175
Weight (kg)
70
Ethnicity (optional)
9 choices
- American Indian or Alaska Native
- Asian
- Black or African American
- Hispanic or Latino
- Middle Eastern or North African
- Native Hawaiian or Pacific Islander
- White or European American
- Multiracial
- Prefer not to say
Are you currently taking any prescription medications?
2 choices
- Yes
- No
If yes, please list all current medications and dosages.
e.g. Metformin 500mg twice daily, Lisinopril 10mg once daily...
Inclusion Criteria — Please confirm all that apply to you.
5 choices
- I am between 18 and 65 years of age
- I have been diagnosed with the condition specified in the study description
- I have not participated in another clinical trial in the past 30 days
- I am able to attend all required study visits
- I can read and understand English (or the study's primary language)
Exclusion Criteria — Please confirm none of the following apply to you.
4 choices
- I do not have any contraindicated conditions listed in the study protocol
- I am not pregnant or breastfeeding
- I do not have a history of the conditions that would disqualify me from this study
- I am not taking any medications that are contraindicated in the protocol
Are you willing and able to attend all required study visits as scheduled?
3 choices
- Yes
- No
- Uncertain — I have scheduling constraints to discuss
Do you consent to being contacted by the research team to discuss your eligibility and next steps?
2 choices
- Yes, I consent to be contacted
- No, do not contact me
Where it fits
Who uses this template
Suggested uses, and why this starting point can help. Adapt the questions to your own process.
Pharmaceutical and biotech companies
Turn initial interest into information you can review. Use the answers to prepare a relevant follow-up and decide whether the opportunity fits your work. Review “Gender” in particular and adapt it to the detail you need.
Academic medical centers
Give participants a clear set of questions and keep the information together, making it easier to prepare, respond and follow up. Review “Height (cm)” in particular and adapt it to the detail you need.
Contract research organizations (CROs)
Gather the details needed before making arrangements. Consistent answers help you spot special requirements and prepare the next step. Review “Weight (kg)” in particular and adapt it to the detail you need.
Hospital research departments
Collect answers in a consistent structure, so you can compare responses while keeping each person’s explanation in context. Review “Ethnicity (optional)” in particular and adapt it to the detail you need.
Independent clinical investigators
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “Are you currently taking any prescription medications?” in particular and adapt it to the detail you need.
Public health intervention study teams
Screens for depression severity scores, prior therapy history, current psychiatric medications, and absence of active suicidality for a CBT intervention trial.
Medical device trial teams
Collects cardiac history, implanted device status, and prior cardiac surgery history to assess eligibility for a wearable cardiac monitoring trial.
What's included
Full contact information including phone for follow-up calls
Date of birth for age eligibility verification
Height and weight fields with validation ranges
Optional ethnicity dropdown for demographic diversity tracking
Current medications field to check for contraindications
Inclusion criteria checklist for participant self-confirmation
Exclusion criteria checklist to surface disqualifying conditions
Explicit contact-consent radio, so outreach only goes to people who agreed to it
How to create a clinical trial screening form
- 1
Click 'Use this template' to open the pre-built clinical trial screening form in the editor.
- 2
Update the study description paragraph with your specific trial name, NCT number, and eligibility overview.
- 3
Customize the inclusion and exclusion criteria checkboxes to match your exact protocol criteria.
- 4
Adjust the height and weight range validators in the number field settings to your study's BMI or anthropometric limits.
- 5
Add any study-specific questions such as prior treatments, comorbidities, or lifestyle factors relevant to your protocol.
- 6
Publish the form and distribute the link on ClinicalTrials.gov, patient advocacy websites, or your institution's recruitment portal.
Best practices for your clinical trial screening form
State study purpose clearly upfront
applicants who understand what the trial is about self-select more accurately, reducing mismatched applications and wasted coordinator time.
List exclusion criteria in plain language
medical jargon in exclusion criteria causes applicants to misinterpret their eligibility; use simple, direct language so the self-screen is accurate.
Include contact consent explicitly
collecting an unambiguous 'yes, contact me' answer protects your organization and establishes a clear record of recruitment outreach consent.
Capture phone numbers
many clinical trial coordinators prefer phone calls for follow-up; having the number captured at screening eliminates an extra data collection step.
Don't over-screen at this stage
limit the digital form to essential criteria and save detailed medical history and laboratory result review for the in-person screening visit.
Set expectations about the timeline
add a note in the intro paragraph about how long it takes to hear back, reducing applicant follow-up calls to your coordinator.
12 form ideas you can build with this template
Diabetes Drug Efficacy Trial Screening
Pre-screens applicants for HbA1c range, current diabetes medications, and absence of renal impairment before scheduling in-person metabolic testing.
Cardiovascular Device Study Screening
Collects cardiac history, implanted device status, and prior cardiac surgery history to assess eligibility for a wearable cardiac monitoring trial.
Oncology Immunotherapy Trial Pre-Screen
Gathers cancer diagnosis, staging, prior treatment lines, and ECOG performance status to determine candidacy for an investigational immunotherapy protocol.
Mental Health Intervention Study Screening
Screens for depression severity scores, prior therapy history, current psychiatric medications, and absence of active suicidality for a CBT intervention trial.
Vaccine Efficacy Trial Recruitment Form
Collects prior vaccination history, immune status, recent infections, and travel history to identify immunologically naive participants for a Phase II vaccine study.
Sleep Disorder Treatment Trial Screening
Asks about polysomnography results, sleep diary data, apnea diagnosis, and current CPAP use to identify candidates for a novel insomnia pharmacotherapy study.
Pediatric Asthma Study Parental Screening
Collects child age, asthma diagnosis, current controller medication, and emergency department visit history through a parent-completed screening form.
Neurodegenerative Disease Biomarker Study
Screens for cognitive assessment scores, family history of neurological conditions, and absence of MRI contraindications for an Alzheimer's biomarker study.
Athletic Performance Intervention Study
Pre-qualifies competitive athletes based on training volume, VO2max estimates, recent injuries, and supplement use for a sports nutrition intervention trial.
Geriatric Fall Prevention Study Screening
Assesses mobility aid use, fall history in the past year, grip strength self-report, and living situation to identify at-risk older adults for a balance intervention trial.
Maternal Health Prenatal Supplement Trial
Screens pregnant participants for gestational age, supplement history, prior pregnancies, and dietary intake to assess eligibility for a prenatal nutrition study.
Chronic Pain Neuromodulation Trial Screening
Collects pain duration, current analgesic use, prior interventional procedures, and pain scale scores to identify candidates for a transcranial stimulation protocol.
Frequently asked questions
Is this form compliant with HIPAA?
formformform is a general-purpose form tool; it is not a covered entity under HIPAA and does not offer a BAA. For clinical trials that collect protected health information (PHI), consult your institution's compliance office about appropriate data handling procedures before using any third-party form tool.
Can I add study-specific eligibility questions?
Yes. In the form editor you can add any field type — radio, checkbox, number, text — to capture protocol-specific eligibility data such as prior treatment history, lab value thresholds, or comorbidity status.
Can applicants save their progress and return later?
formformform forms are submitted in one session. For a long screening form, consider breaking it into sections using the page break field, which allows stepwise completion without losing prior answers.
How do I notify my study coordinator when a new application is submitted?
formformform sends an instant email notification to the form owner on every submission. You can configure the notification email to go to your study coordinator's inbox directly.
Can I use this for pediatric trials that require parental consent?
You can add a parental or guardian consent field and a parent/guardian name field to the form. For complex consent workflows, consult your IRB about appropriate documentation requirements beyond what a web form alone can capture.
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