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Healthcare & Clinical

Family Medical History & Personal Risk Awareness Survey

Captures which health conditions run in a patient's family, which relatives are affected, and how concerned the patient is about their own risk. Built for primary care, genetic counseling, or preventive health intake. An AI follow-up interview digs into the single most concerning condition — who had it, how severe, and whether it has already changed the patient's screening or lifestyle habits.

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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13問・約7分
Q01
メッセージ

Thanks for taking a few minutes to share your family's health background. This helps your care team spot patterns that matter for your own health. Your responses are completely confidential and anonymized. It takes about 5 minutes, and you can skip anything you're unsure of.

Q02
選択式

Which of these blood relatives' medical history do you know reasonably well?

  • Mother
  • Father
  • Sibling(s)
  • Grandparent(s)
  • Aunts/Uncles
  • None of the above
Q03
マトリクス

For each condition, mark which of your blood relatives (that you know of) have had it.

8行 × 5列
  • Heart disease
  • High blood pressure
  • Diabetes
  • Cancer (any type)
  • Stroke
  • ほか3件
列: Mother · Father · Sibling(s) · Grandparent(s) · None that I know of
Q04
選択式必須

Of the conditions in your family, which one concerns you most for your own future health?

  • Heart disease
  • High blood pressure
  • Diabetes
  • Cancer
  • Stroke
  • A mental health condition
  • Alzheimer's or dementia
  • An autoimmune disease
Q05
AIインタビュー

Explore the condition the respondent flagged as most concerning: which relative had it, roughly what age they were when it started, and how severe the outcome was. Find out whether knowing about it has changed the respondent's own health habits, screening schedule, or willingness to get tested. If they weren't sure of the details, ask what they'd want to find out and from whom.

Q06
オピニオンスケール必須

How concerned are you about your own personal risk of developing this condition?

スケール: 1 – 5
最小:Not at all concerned最大:Extremely concerned
Q07
選択式

In the last 12 months, have you discussed your family medical history with a doctor or other healthcare provider?

  • Yes
  • No
  • Not sure
Q08
選択式

Has a healthcare provider ever recommended genetic testing or earlier/more frequent screening based on your family history?

  • Yes
  • No
  • Not sure
Q09
自由回答（長文）

Is there anything else about your family's medical history — conditions, ages, or details — that you think your care team should know?

Q10
選択式

What is your age range?

  • Under 18
  • 18-29
  • 30-44
  • 45-59
  • 60-74
  • 75+
  • Prefer not to say
Q11
選択式

What is your biological sex (relevant for some inherited conditions)?

  • Female
  • Male
  • Intersex
  • Prefer not to say
Q12
選択式

What is your race or ethnicity (some conditions vary in risk by ancestry)?

  • Black or African descent
  • East Asian
  • South Asian
  • Hispanic or Latino
  • Middle Eastern or North African
  • Native American or Indigenous
  • White
  • Multiple ethnicities
  • Prefer not to say
Q13
メッセージ

That's everything — thank you. Your responses will be added to your health record so your care team can flag any conditions worth watching or screening for early.

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 a static family history checklist by using an AI follow-up interview to dig into the one condition the respondent flagged as most concerning — who had it, how severe, and whether it's already changed their screening or lifestyle habits
  • Pairs a relative-by-condition matrix with a personal concern rating (opinion scale) so you capture both objective family history and subjective risk perception in one flow
  • Includes intake-relevant screening questions (recent doctor discussions, genetic testing recommendations) plus age, sex, and ancestry fields relevant to inherited-condition risk
  • Every AI probe uses a transparent, reviewable prompt and produces an auto-generated report, with optional voice AI delivery for patients who prefer speaking over typing

Jotform

Family Medical History Form Template

A static, fillable form template for capturing family medical history, built on Jotform's drag-and-drop form builder. Good for basic intake paperwork but not designed to probe deeper into any single flagged condition. Best suited for practices wanting a simple, customizable PDF/web form rather than a conversational survey.

優れている点

  • Easy to customize fields via Jotform's form builder
  • Familiar form format for clinical intake staff
  • Can integrate with Jotform's broader forms/e-signature ecosystem

物足りない点

  • No adaptive follow-up questioning — it's a fixed set of fields
  • No automated per-response quality scoring or auto-generated interview reports
  • No voice AI interview option

SurveySparrow

Family Medical History Questionnaire Template

A conversational-style questionnaire template covering family medical history, benefiting from SurveySparrow's chat-like survey UI. It presents questions in a friendlier flow than a plain form, but questioning is still pre-scripted rather than adaptive to what the respondent flags as concerning. No indication of AI-driven follow-up probing on flagged conditions.

優れている点

  • Conversational, chat-style presentation improves respondent experience
  • Mobile-friendly survey format
  • Part of a broader survey platform with reporting/dashboard tools

物足りない点

  • No adaptive AI follow-up interview into the most concerning condition
  • No published methodology for how any AI features (if present) generate questions
  • No voice AI interview mode

SurveyMonkey

Medical History Form Template

A general medical history form template, broader than family-history-specific and geared toward standard patient intake. It's a static template within SurveyMonkey's survey builder, offering standard logic/skip patterns but no condition-specific probing. Useful as a generic intake baseline rather than a specialized family-risk assessment.

優れている点

  • Backed by SurveyMonkey's established survey infrastructure and analytics
  • Simple to deploy and distribute at scale
  • Supports standard skip logic for basic branching

物足りない点

  • No adaptive AI interview to explore the single most concerning condition in depth
  • No automated quality scoring of open-text responses
  • Broader medical-history focus, not tailored specifically to family risk/genetic counseling context

Typeform

Family Health History Questionnaire

A one-question-at-a-time family health history questionnaire using Typeform's signature conversational interface. It's visually polished and easy for respondents to complete, but its branching logic is pre-set rather than dynamically generated based on what the respondent identifies as most concerning. No adaptive interviewing or scoring layer.

優れている点

  • Clean, engaging one-question-at-a-time UX
  • Easy conditional logic for basic branching
  • Strong template design and completion-rate optimization

物足りない点

  • No adaptive AI follow-up interview or voice AI option
  • No automated per-response quality scoring
  • No auto-generated clinical/report summary of findings

よくあるご質問

「Family Medical History & Personal Risk Awareness Survey」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13問含まれており、最初の設問は次のとおりです：「Thanks for taking a few minutes to share your family's health background. This helps your care team spot patterns that m…」・「Which of these blood relatives' medical history do you know reasonably well?」・「For each condition, mark which of your blood relatives (that you know of) have had it.」。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、13問を約7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。

このテンプレートを使う無料で始める

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