--- title: "Free Clinical Trial Screening Form Template | formformform" description: "Free clinical trial screening form template. Collect applicant demographics, medical history, inclusion/exclusion criteria confirmation, and contact consent…" url: "https://www.formformform.com/templates/clinical-trial-screening-form" type: static generatedAt: "2026-09-16T13:11:47.237Z" --- [Templates](https://www.formformform.com/form-templates)/[Research & Science Forms](https://www.formformform.com/form-templates/research-forms) # 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. [Use this template](https://app.formformform.com/templates/clinical-trial-screening-form/use) Last updated 21 August 2026 ## Fields in this template - Full Name · required - Email Address · required - Phone Number · required - Date of Birth · required - Gender · required Male · Female · Non-binary · Prefer not to say · Other - Height (cm) · required - Weight (kg) · required - Ethnicity (optional) 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? · required Yes · No - If yes, please list all current medications and dosages. - Inclusion Criteria — Please confirm all that apply to you. · required 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. · required 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? · required 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? · required Yes, I consent to be contacted · No, do not contact me ## Who uses this template Clinical research coordinators · Pharmaceutical and biotech companies · Academic medical centers · Contract research organizations (CROs) · Hospital research departments · Independent clinical investigators · Public health intervention study teams · Medical device trial teams ## 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. 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. ## 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. ## 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. 1 Click 'Use this template' to open the pre-built clinical trial screening form in the editor. 2. 2 Update the study description paragraph with your specific trial name, NCT number, and eligibility overview. 3. 3 Customize the inclusion and exclusion criteria checkboxes to match your exact protocol criteria. 4. 4 Adjust the height and weight range validators in the number field settings to your study's BMI or anthropometric limits. 5. 5 Add any study-specific questions such as prior treatments, comorbidities, or lifestyle factors relevant to your protocol. 6. 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. ## 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. ## Related templates [Legal Forms Research Study Consent Form Collect informed consent from research participants with full IRB-ready detail.](https://www.formformform.com/templates/research-participant-consent-form)[Research & Science Forms Academic Research Survey Collect participant data for academic studies with informed consent built in.](https://www.formformform.com/templates/academic-research-survey-form)[Research & Science Forms IRB / Ethics Review Application Collect structured research ethics applications for IRB review committees.](https://www.formformform.com/templates/irb-research-application-form)[Research & Science Forms Laboratory Data Collection Form Log experimental measurements, sample details, and lab observations digitally.](https://www.formformform.com/templates/lab-data-collection-form)[Research & Science Forms Research Study Participant Feedback Collect participant experience feedback after a research study session.](https://www.formformform.com/templates/research-feedback-form)[Research & Science Forms Field Research Data Entry Form Log field observations, species counts, and environmental data digitally in the field.](https://www.formformform.com/templates/field-research-data-form) ## More Research & Science form templates - [Conference Abstract Submission template](https://www.formformform.com/templates/conference-abstract-submission-form) [View all Research & Science form templates →](https://www.formformform.com/form-templates/research-forms) Start with the Clinical Trial Screening Form template Free forever. No credit card required. Customize everything. [Use this template](https://app.formformform.com/templates/clinical-trial-screening-form/use)