--- title: Patient Assessment Form product: PDF Generator description: Get a printable patient assessment form in PDF. Generate editable or prefilled healthcare evaluation forms using SurveyJS PDF Generator. framework: Vanilla JS source: https://surveyjs.io/pdf-generator/examples/pdf-healthcare-patient-assessment-form-template/vanillajs index: https://surveyjs.io/pdf-generator/examples/overview.md --- # Patient Assessment Form (Vanilla JS) ## Files ### `public/index.html` ```html
``` ### `src/index.css` ```css /* You can add your custom CSS here. */ ``` ### `src/index.js` ```js import { Model } from "survey-core"; import "survey-js-ui"; import { SurveyPDF } from "survey-pdf"; import "survey-core/survey-core.min.css"; import "./index.css"; import { json } from "./json"; function createSurveyPdfModel (surveyModel) { const surveyPDF = new SurveyPDF(json); if (surveyModel) { surveyPDF.data = surveyModel.data; surveyPDF.locale = surveyModel.locale; } return surveyPDF; } function saveSurveyToPdf (filename, surveyModel) { const pdfDoc = createSurveyPdfModel(surveyModel); if (!pdfDoc) return; pdfDoc.save(filename); } const previewDiv = document.getElementById("pdf-preview"); const previewEmbed = document.getElementById("pdf-preview-frame"); let pdfBlobUrl; function showPdfPreview(surveyModel) { if (!previewDiv || !previewEmbed) return; const pdfDoc = createSurveyPdfModel(surveyModel); if (!pdfDoc) return; pdfDoc.raw("blob").then((blob) => { if (pdfBlobUrl) { URL.revokeObjectURL(pdfBlobUrl); } pdfBlobUrl = URL.createObjectURL(blob); previewEmbed.setAttribute("src", pdfBlobUrl); previewDiv.style.display = "block"; }); } function previewPdf(surveyModel) { if (!previewDiv) return; if (previewDiv.style.display !== "none") { previewDiv.style.display = "none"; return; } showPdfPreview(surveyModel); } const survey = new Model(json); survey.showCompleteButton = false; survey.navigationButtonsLocation = "topBottom"; survey.addNavigationItem({ id: "survey_save_as_file", title: "Download PDF", action: () => { saveSurveyToPdf("surveyResult.pdf", survey); } }); survey.addNavigationItem({ id: "survey_pdf_preview", title: "Preview PDF", visible: window.navigator.pdfViewerEnabled, action: () => { previewPdf(survey); } }); survey.render(document.getElementById("surveyElement")); ``` ### `src/json.js` ```js export const json = { "title": "Patient Assessment Form", "pages": [ { "name": "Patient information", "title": "Patient information", "elements": [ { "type": "panel", "name": "patient-information", "title": "All fields with an asterisk (*) are required fields, and must be filled out in order to process the information in strict confidentiality.", "elements": [ { "type": "text", "name": "first-name", "title": "First name", "isRequired": true }, { "type": "text", "name": "last-name", "startWithNewLine": false, "title": "Last name", "isRequired": true }, { "type": "text", "name": "ssn", "title": "Social Security number", "isRequired": true, "requiredErrorText": "You SSN must be a 9-digit number.", "validators": [ { "type": "regex", "text": "Your SSN must be a 9-digit number", "regex": "^(?!0{3})(?!6{3})[0-8]\\d{2}-?(?!0{2})\\d{2}-?(?!0{4})\\d{4}$" } ], "maxLength": 9 }, { "type": "text", "name": "birthdate", "startWithNewLine": false, "title": "Date of birth", "isRequired": true, "inputType": "date" }, { "type": "text", "name": "concerns", "title": "List any concerns you want to talk about during your visit" } ] } ] }, { "name": "Health history", "title": "Health history", "elements": [ { "type": "panel", "name": "health-history", "elements": [ { "type": "boolean", "name": "diabetes", "startWithNewLine": false, "title": "Do you have diabetes?" }, { "type": "boolean", "name": "high-blood-pressure", "startWithNewLine": false, "title": "High blood pressure?" }, { "type": "boolean", "name": "high-cholesterol", "startWithNewLine": false, "title": "High cholesterol?" }, { "type": "comment", "name": "other-health-conditions", "title": "Do you have other health conditions?", "maxLength": 300 } ] } ] }, { "name": "Social history", "title": "Social history", "elements": [ { "type": "panel", "name": "smoking", "title": "Smoking", "elements": [ { "type": "radiogroup", "name": "cigarettes", "title": "Do you smoke cigarettes?", "choices": [ { "value": "never", "text": "Never" }, { "value": "yes", "text": "Yes" }, { "value": "quit", "text": "Quit" } ] }, { "type": "text", "name": "packs-a-day", "title": "If yes, how many packs a day?", "inputType": "number", "min": 0 }, { "name": "date-quit", "type": "text", "inputType": "date", "title": "If you are no longer a smoker, enter the date you quit." }, { "name": "years-smoked", "type": "text", "inputType": "number", "title": "How many years have you smoked?", "min": 0 }, { "type": "boolean", "name": "vape", "title": "Do you vape (e-cigarettes)?" } ] }, { "type": "panel", "name": "alcohol-use-history", "title": "Alcohol use", "startWithNewLine": false, "elements": [ { "type": "boolean", "name": "alcohol", "title": "Do you drink alcohol?" }, { "type": "text", "name": "drinks-per-week", "title": "If yes, how many drinks per week?", "inputType": "number", "min": 0 } ] }, { "type": "panel", "name": "drug-use-history", "title": "Drug use", "elements": [ { "type": "checkbox", "name": "recreational-drugs", "title": "Do you use recreational drugs?", "choices": [ { "value": "rarely", "text": "Rarely" }, { "value": "marijuana", "text": "Marijuana" }, { "value": "cocaine", "text": "Cocaine" }, { "value": "opioids", "text": "Opioids" } ], "showOtherItem": true, "showNoneItem": true, "otherPlaceholder": "Please specify... ", "noneText": "Never", "otherText": "Other", "colCount": 3 }, { "type": "text", "name": "drug-use-times-per-month", "title": "How many times per month", "description": "If you take different types of drugs, please specify the frequency of use for each in a 'drug - # times/month' format." } ] }, { "type": "panel", "name": "personal-info", "title": "Personal information", "elements": [ { "type": "radiogroup", "name": "education", "title": "What is your highest level of education completed?", "choices": [ { "value": "high-school", "text": "High School" }, { "value": "trade-school", "text": "Trade School" }, { "value": "college", "text": "College" }, { "value": "post-graduate", "text": "Post-graduate degree(s)" } ] }, { "type": "radiogroup", "name": "marital-status", "title": "What is your marital status?", "choices": [ { "value": "married", "text": "Married" }, { "value": "partnership", "text": "Partnership" }, { "value": "divorced", "text": "Divorced" }, { "value": "separated", "text": "Separated" }, { "value": "single", "text": "Single" }, { "value": "widow", "text": "Widow(er)" } ] } ] }, { "type": "panel", "name": "sexual-life", "title": "Sexual life", "startWithNewLine": false, "elements": [ { "type": "boolean", "name": "sexually-active", "title": "Are you sexually active?" }, { "type": "text", "name": "sexual-partners-number", "title": "How many sexual partners do you have?", "inputType": "number", "min": 0 }, { "type": "radiogroup", "name": "sexual-partners-gender", "titleLocation": "hidden", "choices": [ { "value": "men", "text": "Men" }, { "value": "women", "text": "Women" }, { "value": "both", "text": "Both" } ], "colCount": 3 }, { "type": "radiogroup", "name": "contraception", "title": "Do you use contraception?", "showCommentArea": true, "commentText": "If yes, what method?", "choices": [ { "value": "yes", "text": "Yes" }, { "value": "no", "text": "No" } ] } ] }, { "type": "panel", "name": "children", "title": "Children", "elements": [ { "type": "boolean", "name": "have-children", "title": "Do you have children?" }, { "type": "text", "name": "children-number", "title": "# of children" }, { "type": "text", "name": "ages", "title": "Their ages" } ] }, { "type": "panel", "name": "employment-exercises", "title": "Employment and physical activity", "startWithNewLine": false, "elements": [ { "type": "radiogroup", "name": "employment", "title": "Are you employed?", "showCommentArea": true, "commentText": "Type of work", "choices": [ { "value": "yes", "text": "Yes" }, { "value": "no", "text": "No" }, { "value": "retired", "text": "Retired" } ], "colCount": 3 }, { "type": "radiogroup", "name": "do-exercise", "title": "Do you exercise?", "choices": [ { "value": "yes", "text": "Yes" }, { "value": "no", "text": "No" } ], "colCount": 2 }, { "type": "text", "name": "activity-type", "title": "Type of physical activity" }, { "type": "text", "name": "activity-frequency", "title": "How often" }, { "type": "text", "name": "activity-duration", "title": "How long per activity" } ] } ] }, { "name": "Surgical history / recent hospitalizations", "title": "Surgical history / recent hospitalizations", "elements": [ { "type": "comment", "name": "surgery-description", "title": "Date and type of surgery / procedure" } ] }, { "name": "Family history", "title": "Family history", "elements": [ { "type": "matrixdynamic", "name": "family-history", "titleLocation": "hidden", "columns": [ { "name": "relation", "title": "Relation" }, { "name": "health-conditions", "title": "Health conditions" }, { "name": "cancer-history", "title": "Family history of cancer" } ], "cellType": "text", "rowCount": 3, "allowRemoveRows": false } ] }, { "name": "Preventive care", "title": "Preventive care", "elements": [ { "type": "panel", "name": "preventive-care", "elements": [ { "type": "panel", "name": "recent-shots-panel", "elements": [ { "type": "matrixdropdown", "name": "recent-shots", "title": "Recent shots from a doctor or pharmacist", "columns": [ { "name": "date", "title": "Date" }, { "name": "place", "title": "Place" } ], "cellType": "text", "rows": [ { "value": "flu", "text": "Flu" }, { "value": "shingles", "text": "Shingles" }, { "value": "pneumonia", "text": "Pneumonia" }, { "value": "tetanus", "text": "Tetanus" }, { "value": "other", "text": "Other" } ] } ] }, { "type": "panel", "name": "recent-tests-panel", "startWithNewLine": false, "elements": [ { "type": "matrixdropdown", "name": "recent-tests", "title": "Recent tests or procedures", "columns": [ { "name": "date", "title": "Date" }, { "name": "place", "title": "Place" } ], "cellType": "text", "rows": [ { "value": "colonoscopy", "text": "Colonoscopy" }, { "value": "cologuard", "text": "Cologuard" }, { "value": "mammogram", "text": "Mammogram" }, { "value": "pap", "text": "PAP" }, { "value": "other", "text": "Other" } ] } ] }, { "type": "panel", "name": "specialists-panel", "elements": [ { "type": "matrixdynamic", "name": "specialists", "title": "Specialists", "columns": [ { "name": "provider", "title": "Provider's first and last name" }, { "name": "speciality", "title": "Speciality" }, { "name": "city", "title": "Town/City" } ], "cellType": "text", "rowCount": 3 } ] }, { "type": "panel", "name": "medications-and-allergies", "elements": [ { "type": "multipletext", "name": "medications", "title": "Medications", "items": [ { "name": "medication-name", "title": "Name" }, { "name": "medication-dose", "title": "Dose" }, { "name": "medication-times-per-day", "title": "Times per day" } ] }, { "type": "multipletext", "name": "allergies", "startWithNewLine": false, "title": "Allergies", "items": [ { "name": "allergy-type", "title": "Type" }, { "name": "allergy-reaction", "title": "Reaction" } ] } ] } ] } ] }, { "name": "Symptoms", "title": "Symptoms", "elements": [ { "type": "checkbox", "name": "symptoms", "title": "Please select any symptoms you have now or have had in the past month.", "choices": [ "Fever", "Chills", "Feeling poorly", "Feeling tired", "Weight gain", "Weight loss", "Chest pain", "Heart pounding", "Fast pulse", "Slow pulse", "Leg pain with exercise", "Leg swelling", "Joint pain", "Neck pain", "Joint swelling", "Joint stiffness", "Muscle aches", "Back pain", "Sores", "Rash", "Itching", "Change in a mole", "Unusual growth/spot" ], "colCount": 3 }, { "type": "signaturepad", "name": "signature", "title": "Signature", "signatureHeight": 100 }, { "type": "text", "name": "current-date", "startWithNewLine": false, "title": "Date", "inputType": "date" } ] } ], "questionErrorLocation": "bottom", "questionsOnPageMode": "singlePage", "headerView": "advanced" }; ``` ### `src/theme.js` ```js export const themeJson = {}; ``` ### `package.json` ```json { "dependencies": { "survey-core": "latest", "survey-js-ui": "latest", "survey-pdf": "latest" } } ``` ## Other Frameworks - [Angular](https://surveyjs.io/pdf-generator/examples/pdf-healthcare-patient-assessment-form-template/angular.md) - [React](https://surveyjs.io/pdf-generator/examples/pdf-healthcare-patient-assessment-form-template/reactjs.md) - [Vue 3](https://surveyjs.io/pdf-generator/examples/pdf-healthcare-patient-assessment-form-template/vue3js.md) - [jQuery](https://surveyjs.io/pdf-generator/examples/pdf-healthcare-patient-assessment-form-template/jquery.md)