Intake form for Online Issues

I recently found an "email evaluation scorecard" Forrester put out at the end of last year. Of course, I immediately thought "Wow, wouldn't it be great if clients would fill out something like this for their in-place online initiatives (websites, present marketing, etc.)?" I'm thinking something like an intake form at the dr's office. Short and sweet:

We have these symptoms, we have a history of these things, and we're allergic to this. Here are our test scores (metrics). We got a previous diagnosis of blah, treated it in this manner, and had these results. Ah, the parallels!

I think in most organizations, people tend to know what's wrong but it's often hard to organize their thoughts. And for someone trying to solve their problems, it sure would be helpful to know their "online history."