This Inclusive Language for Intake Form is also available in Word (18 KB)
Below are examples of language you could use on your patient intake forms to ensure an inclusive and affirming patient experience. These questions align with United States Core Data for Interoperability Draft Version 5; however, depending on your electronic health record, you may need to make modifications to record patient information accurately.
What name would you like us to use?
Legal name (on insurance records or driver's license):
Current relationship status:
What is your preferred language?
Do you need a language interpreter?
For minors: Consider "Parent/Guardian 1," "Parent/Guardian 2," "Parent/Guardian 3," and "Parent/Guardian 4" to accommodate nontraditional family configurations.
For health history: Ask about "blood relatives" rather than "family."
Checkbox Alternatives
Checkboxes are commonly used in forms that are completed electronically. Even on paper forms, checkboxes make data entry easier.
Current relationship status (check all that apply):
- Not currently in a relationship
- In a relationship
- Never married
- Currently married
- Separated
- Divorced
- Widowed
- I use a different term:
- Prefer not to answer
What is your preferred language?
Do you need a language interpreter?
- Yes
- No
