Q01
メッセージ
すべてのテンプレートIndustry-Specific
Biopsychosocial Assessment for Clinical Intake
A structured intake tool for clinicians, counselors, and case managers that maps a client's physical health, mood and coping patterns, and social/environmental context into one whole-person profile. An AI follow-up interview explores the client's self-identified top stressor in their own words, surfacing how biological, psychological, and social factors interact in daily life.
設問の例
テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。
全16問・約8分
Q02
同意必須
Before we begin, please review this statement.
Q03
評価スケール必須
Right now, how would you rate your overall physical health?
範囲: 1 – 5
最小:Poor最大:Excellent
Q04
スライダーマトリクス必須
Over the last 2 weeks, how would you rate each of the following?
4行（各行にスライダー1つ）
- Sleep quality
- Energy level
- Physical pain or discomfort
- Appetite or eating patterns
スライダー 0〜10最小:Very poor最大:Very good
Q05
自由回答（短文）
Please list any current medical conditions, medications, or ongoing treatments (write 'none' if not applicable).
Q06
選択式必須
In the last 30 days, how often have you used alcohol or other substances to cope with stress or emotions?
- Never
- Rarely
- About once a week
- Several times a week
- Daily
Q07
オピニオンスケール必須
Over the last 2 weeks, how would you rate your overall stress level?
スケール: 0 – 10
最小:No stress at all最大:Overwhelming stress
Q08
マトリクス必須
In the last 2 weeks, how often have you experienced each of the following?
4行 × 5列
- Feeling anxious or on edge
- Feeling down, hopeless, or unmotivated
- Trouble concentrating or making decisions
- Feeling supported by people around you
列: Never · Rarely · Sometimes · Often · Always
Q09
選択式必須
Which best describes your current living situation?
- Living alone
- Living with family or a partner
- Living with roommates
- Temporary, shared, or unstable housing
- Currently without stable housing
Q10
選択式必須
In the last 30 days, how often have money worries affected your ability to cover basics like food, housing, or medication?
- Never
- Rarely
- Sometimes
- Often
- Almost always
Q11
自由回答（短文）必須
What is the single biggest source of stress in your life right now?
Q12
AIインタビュー
Using the respondent's answer about their biggest current stressor, explore how it connects to their physical health, mood, and living situation — ask how it affects their sleep, daily functioning, or relationships, and what they've already tried to manage it. Anchor on any specific frequency or scale answers they gave earlier (sleep, stress, mood, financial strain) and ask them to walk through one concrete recent example. If the respondent expresses thoughts of self-harm, hopelessness, or safety concerns, do not attempt to counsel or diagnose — acknowledge it, gently ask if they are safe right now, and encourage them to contact a crisis line or their care provider before continuing.
Q13
プルダウン
What is your age range?
- Under 18
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65+
- Prefer not to say
Q14
選択式
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer not to say
Q15
選択式
What is your current employment status?
- Employed full-time
- Employed part-time
- Unemployed and looking
- Unable to work
- Retired
- Student
- Prefer not to say
Q16
メッセージ
Thank you for sharing all of this. Your responses will go directly to your care team to help build a plan that fits your whole life, not just one part of it.
含まれる機能
AIによる深掘り
自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。
注意確認設問
急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。
AIが作成する設問文
文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。
自動レポート
回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。
他ツールとの比較
ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。
このテンプレートを選ぶ理由
- Goes beyond static fields by using an AI follow-up interview that explores the client's self-identified top stressor in their own words, surfacing how biological, psychological, and social factors interact in daily life
- Combines standardized clinical screening formats (rating, slider matrix, opinion scale, matrix) covering physical health, mood, coping, and stress with open-ended narrative capture
- Screens for high-risk context factors like substance use for coping and financial strain affecting basic needs, alongside living situation and demographics for a whole-person profile
- Frames the intake with a consent step and a warm closing message so clients understand how responses will be used by their care team, supporting transparent, ethical data collection
Jotform
Biopsychosocial Assessment Form TemplateA ready-to-field static form template covering biological, psychological, and social intake domains, built on Jotform's drag-and-drop form builder. It's structured for direct clinical use but relies entirely on fixed fields with no dynamic follow-up capability. Customization is manual, requiring the clinician to edit questions themselves for each client population.
優れている点
- Fielding-ready template usable immediately without custom setup
- Backed by Jotform's broad form-building ecosystem (conditional logic, integrations, e-signatures)
- Familiar, easy-to-edit interface for non-technical clinical staff
物足りない点
- Static question set with no adaptive AI follow-up to probe a client's stated stressor in their own words
- No automated per-response quality scoring or auto-generated clinical summary report
- No transparent, published interview prompt/methodology for the follow-up questions since none exist
Typeform
Biopsychosocial Assessment Form TemplateTypeform offers a conversational-style, one-question-at-a-time biopsychosocial template that's pleasant to fill out and mobile-friendly. It captures the same broad intake domains but as a fixed sequence of questions rather than an adaptive dialogue. There's no mechanism for the tool itself to explore a client's answers more deeply.
優れている点
- Polished, conversational UI that can reduce respondent friction compared to traditional forms
- Fielding-ready and easy to brand/customize visually
- Good mobile completion experience
物足りない点
- No adaptive AI interview or voice AI option to explore open-ended answers like a top stressor
- No automated quality scoring per response or auto-generated clinical report
- Question flow is pre-set, so it cannot surface interacting biopsychosocial factors dynamically
SurveySparrow
Counselling Intake Assessment Form Template | Export PDF FormsThis is a counselling-focused intake template with PDF export, aimed at capturing client background for therapists rather than a full biopsychosocial structure specifically. It's a static, fielding-ready form suited to general counselling paperwork. It doesn't offer any AI-driven exploration of a client's presenting stressor.
優れている点
- Fielding-ready and tailored to counselling/intake workflows
- PDF export supports clinical recordkeeping and offline documentation needs
- Likely offers conversational survey formatting typical of SurveySparrow's builder
物足りない点
- No adaptive AI or voice interview to probe the client's stated top stressor in their own words
- No automated per-response quality scoring or auto-generated whole-person report
- Template is oriented to general counselling intake rather than a structured biological/psychological/social mapping
よくあるご質問
「Biopsychosocial Assessment for Clinical Intake」テンプレートにはどのような設問が含まれていますか？
すぐに使える設問が16問含まれており、最初の設問は次のとおりです：「Welcome! This intake helps your care team understand your health, mood, and life circumstances together — not just one p…」・「Before we begin, please review this statement.」・「Right now, how would you rate your overall physical health?」。すべての設問は上でプレビューでき、自由に編集できます。
このアンケートの回答にはどのくらい時間がかかりますか？
回答者は通常、16問を約8分で回答し終えます。
テンプレートは編集できますか？
はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。
このテンプレートは無料で使えますか？
はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。
公開の準備はできましたか？
このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。
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