Heart failure intake that captures hospitalization history up front
Patients answer questions about diagnosis status, current symptom severity, and conditions like diabetes or kidney issues, then upload recent medical records or test results before the intake reaches your team.
The exact intake your heart failure management leads complete
This is the real 6-question guided intake for Heart Failure Management — the same flow your customers finish before you ever pick up the phone.
What a qualified heart failure management lead should tell you
Structured intake for patients managing an existing or suspected heart failure diagnosis, capturing symptom trajectory, current cardiology care status, and comorbidities that affect urgency and treatment planning.
- Doctor Diagnosed Patient With
- Best Describes Current Symptom
- Patient Under Care Cardiologist
- Relationship Patient
- Patient Have Recent Medical
- Factors Apply Patient'S Health
The questions your team needs answered
Every heart failure management intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| Has a doctor diagnosed the patient with heart failure? | A confirmed diagnosis distinguishes a known heart failure patient needing management from someone with undiagnosed symptoms who may need a different evaluation path. |
| Which best describes the current symptom situation? | The symptom trajectory option chosen is the clearest single signal of how quickly this lead needs to be seen, since sudden severe symptoms score well above a stable check-in. |
| Is the patient currently under the care of a cardiologist? | Knowing whether a cardiologist is already involved tells staff if this is a new referral or an existing patient reporting a change that needs faster attention. |
| What is your relationship to the patient? | Identifying whether the patient or a caregiver is submitting determines who staff should contact and whether consent needs confirming before scheduling. |
| Does the patient have recent medical records or test results available to share? | Confirming that records or test results exist lets staff prepare for the visit with actual history instead of relying only on self-reported symptoms. |
| Which factors currently apply to the patient's health situation? | Selected comorbidities like recent hospitalization, kidney issues, or diabetes compound risk and raise the lead's score beyond what the symptom question alone would indicate. |
How Cliont scores heart failure management leads
Every answer is weighted automatically — no manual review required.
Value signals
- Doctor Diagnosed Patient With: yes
- Stable, well-controlled symptoms
- Symptoms gradually worsening
- New, unevaluated symptoms
- Other diagnosed heart conditions
- Kidney-related health issues
Urgency signals
- Sudden severe symptoms
See the lead your team receives
Heart Failure Management Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for heart failure management workflows
| Cliont capability | Heart Failure Management application |
|---|---|
| Conditional relationship branching | When a caregiver or family member submits on the patient's behalf, the intake flags the submission differently so staff know to verify patient consent before booking. |
| Weighted scoring engine | Sudden severe symptoms and recent hospitalization are weighted above a stable, well-controlled check-in, so the more urgent heart failure cases surface first in your CRM. |
| Document upload capture | Patients are prompted to share recent medical records or test results at intake, so a diagnosis history or lab result is already attached before staff review. |
| Multi-select comorbidity capture | The health factors question captures diabetes, kidney issues, other cardiac conditions, and recent hospitalization together, giving staff a fuller risk picture than a single symptom answer alone. |
| CRM lead routing | Qualified heart failure leads, along with their diagnosis status, symptom severity, and comorbidity answers, are sent directly into your CRM instead of sitting in a shared inbox. |
Common heart failure management lead scenarios
Newly diagnosed, unevaluated symptoms
A patient reports new symptoms and has not yet been evaluated, with no confirmed diagnosis or existing cardiologist on record, so the intake flags them for initial workup rather than routine follow-up.
Established patient, worsening symptoms
A diagnosed heart failure patient already under cardiology care reports gradually worsening symptoms, which the intake scores higher than a stable check-in to prompt sooner scheduling.
Caregiver reporting sudden symptoms
A family member submits the intake on behalf of a patient with sudden severe symptoms, and the relationship field lets staff know they're coordinating with a caregiver, not the patient directly.
Recent hospitalization follow-up
A patient recently hospitalized for heart symptoms selects that factor along with an existing cardiac condition, pushing the lead's score above a routine stable-symptom submission.
Stable patient, routine comorbidities
A patient with well-controlled symptoms and diabetes as their only additional factor submits the intake for a standard check-in, which the scoring engine treats as lower urgency than a symptom-change case.
Connect Cliont to your workflow
Send leads
HubSpot, HighLevel, Salesforce, JobNimbus
Book visits
Google Calendar, Outlook Calendar, Calendly
Notify your team
Email, SMS, Slack
Automate follow-up
Zapier, Webhooks, API
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More cardiology intake templates
Heart Failure Management lead-intake FAQs
How does the intake handle a caregiver filling out the form instead of the patient?
The relationship question identifies whether the submission comes from the patient, a family member, or someone else, so your team knows immediately who to contact and whether patient consent needs to be confirmed before scheduling.
What happens if the patient hasn't been formally diagnosed with heart failure yet?
The diagnosis question is answered as yes or no rather than assumed, so undiagnosed but symptomatic patients are still captured and routed appropriately instead of being filtered out.
Can the intake tell a routine check-in apart from a symptom emergency?
The symptom situation question separates stable, gradually worsening, sudden severe, and new unevaluated presentations, and each option carries a different weight so sudden severe symptoms score well above a stable check-in.
Does the form check whether the patient already has a cardiologist?
Yes, the intake asks whether the patient is currently under a cardiologist's care, which helps your staff distinguish a new referral from an existing patient reporting a change in status.
What medical documentation does the intake collect before the lead reaches us?
The intake asks whether recent medical records or test results are available and prompts for uploads, so staff aren't starting from a blank chart when reviewing a heart failure lead.
How are comorbidities like diabetes or kidney issues factored into scoring?
The health factors question lets patients select multiple applicable conditions, including diabetes, kidney-related issues, other heart conditions, or recent hospitalization, and each selected factor adds to the lead's overall score.
Turn heart failure management visitors into qualified patients
Give every heart failure management visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.