---
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: Vue 3
source: https://surveyjs.io/pdf-generator/examples/pdf-healthcare-patient-assessment-form-template/vue3js
index: https://surveyjs.io/pdf-generator/examples/overview.md
---

# Patient Assessment Form (Vue 3)

## Files

### `public/index.html`

```html
<div style="display: flex;">
    <div id="app" style="flex: 1 1 0%; height: 100%; min-width: 0;"></div>
    <div id="pdf-preview" style="flex: 0.7 0.7 0%; display: none">
        <embed id="pdf-preview-frame" type="application/pdf" style="width:100%; height:100%;" />
    </div>
</div>
```

### `src/App.vue`

```html
<template>
    <SurveyComponent :model="survey" />
</template>
<script setup lang="ts">
    import { Model } from "survey-core";
    import { SurveyComponent } from "survey-vue3-ui";
    import "survey-core/survey-core.min.css";
    import { SurveyPDF } from "survey-pdf";
    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);
        }
    });
</script>
```

### `src/index.css`

```css
/* You can add your custom CSS here. */
```

### `src/json.ts`

```ts
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/main.ts`

```ts
import { createApp } from "vue";
import App from "./App.vue";

const app = createApp(App);
app.mount("#app");
```

### `src/shims-vue.d.ts`

```ts
/* eslint-disable */
declare module "*.vue" {
    import type { DefineComponent } from "vue"
    const component: DefineComponent<{}, {}, any>
    export default component
}
```

### `src/theme.ts`

```ts
export const themeJson = {};
```

### `.eslintrc.js`

```js
module.exports = {
    root: true,
    env: {
        node: true
    },
    extends: [
        "plugin:vue/vue3-essential",
        "eslint:recommended",
        "@vue/typescript/recommended",
        "@vue/prettier",
        "@vue/prettier/@typescript-eslint"
    ],
    parserOptions: {
        ecmaVersion: 2020
    },
    rules: {
        "no-console": process.env.NODE_ENV === "production" ? "warn" : "off",
        "no-debugger": process.env.NODE_ENV === "production" ? "warn" : "off"
    },
    overrides: [
        {
            files: [
                "**/__tests__/*.{j,t}s?(x)",
                "**/tests/unit/**/*.spec.{j,t}s?(x)"
            ],
            env: {
                jest: true
            }
        }
    ]
};
```

### `babel.config.js`

```js
module.exports = {
  presets: ["@vue/cli-plugin-babel/preset"]
};
```

### `package.json`

```json
{
  "name": "surveyjs-library-vue3",
  "version": "0.1.0",
  "scripts": {
    "serve": "vue-cli-service serve",
    "build": "vue-cli-service build",
    "lint": "vue-cli-service lint"
  },
  "dependencies": {
    "core-js": "^3.6.5",
    "tslib": "2.6.1",
    "vue": "^3.4.1",
    "survey-core": "latest",
    "survey-pdf": "latest",
    "survey-vue3-ui": "latest",
    "vue-router": "^4.0.0-0",
    "vuex": "^4.0.0-0"
  },
  "devDependencies": {
    "@typescript-eslint/eslint-plugin": "^2.33.0",
    "@typescript-eslint/parser": "^2.33.0",
    "@vue/cli-plugin-babel": "~4.5.0",
    "@vue/cli-plugin-eslint": "~4.5.0",
    "@vue/cli-plugin-pwa": "~4.5.0",
    "@vue/cli-plugin-router": "~4.5.0",
    "@vue/cli-plugin-typescript": "~4.5.0",
    "@vue/cli-plugin-vuex": "~4.5.0",
    "@vue/cli-service": "~4.5.0",
    "@vue/compiler-sfc": "^3.0.0",
    "@vue/eslint-config-prettier": "^6.0.0",
    "@vue/eslint-config-typescript": "^5.0.2",
    "@vue/test-utils": "^2.0.0-0",
    "eslint": "^6.7.2",
    "eslint-plugin-prettier": "^3.1.3",
    "eslint-plugin-vue": "^7.0.0-0",
    "node-sass": "^4.12.0",
    "prettier": "^1.19.1",
    "sass-loader": "^8.0.2",
    "typescript": "~3.9.3"
  }
}
```

### `tsconfig.json`

```json
{
  "compilerOptions": {
    "target": "esnext",
    "module": "esnext",
    "strict": true,
    "jsx": "preserve",
    "importHelpers": true,
    "moduleResolution": "node",
    "skipLibCheck": true,
    "esModuleInterop": true,
    "allowSyntheticDefaultImports": true,
    "sourceMap": true,
    "baseUrl": ".",
    "types": [
      "webpack-env",
      "jest"
    ],
    "paths": {
      "@/*": [
        "src/*"
      ]
    },
    "lib": [
      "esnext",
      "dom",
      "dom.iterable",
      "scripthost"
    ]
  },
  "include": [
    "src/**/*.ts",
    "src/**/*.tsx",
    "src/**/*.vue",
    "tests/**/*.ts",
    "tests/**/*.tsx"
  ],
  "exclude": [
    "node_modules"
  ]
}
```

## 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)
- [jQuery](https://surveyjs.io/pdf-generator/examples/pdf-healthcare-patient-assessment-form-template/jquery.md)
- [Vanilla JS](https://surveyjs.io/pdf-generator/examples/pdf-healthcare-patient-assessment-form-template/vanillajs.md)