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すべてのテンプレート
Industry-Specific

New Patient Veterinary Intake & Health History Survey

Captures a pet's health history, current symptoms, behavior, and vaccination status before a veterinary visit, for clinics streamlining new or returning patient check-ins. The AI follow-up interview reconstructs the timeline and details of the pet's main symptom so staff arrive at the exam room already briefed.

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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

Welcome! Before your pet's visit, we'd like to gather some background so the veterinary team is fully prepared. Your responses are completely confidential and anonymized. This takes about 5 minutes and covers your pet's health history and today's concern.

Q02
選択式必須

What is the primary reason for today's visit?

  • Wellness or annual checkup
  • New symptom or injury
  • Follow-up on an ongoing condition
  • Vaccination only
  • Surgery or procedure
Q03
プルダウン必須

What type of animal are you bringing in today?

  • Dog
  • Cat
  • Bird
  • Rabbit
  • Reptile
  • Other small mammal
  • Other
Q04
数値必須

How old is your pet, in years? (Enter 0 if under 1 year old.)

Q05
選択式

Including today, how many times has your pet seen a veterinarian in the last 12 months?

  • This is the first visit
  • 1 time
  • 2-3 times
  • 4 or more times
Q06
選択式必須

Which of the following currently apply to your pet? Select all that apply.

  • Known allergies
  • A chronic condition (e.g., diabetes, arthritis)
  • Currently on medication or supplements
  • Recent surgery or injury
Q07
自由回答（長文）

List any current medications, supplements, or known allergies, including dosage if known. Leave blank if none.

Q08
スライダーマトリクス必須

Compared to normal, how has your pet been doing in the past week?

4行（各行にスライダー1つ）
  • Appetite
  • Energy level
  • Water intake
  • Bathroom habits (frequency or consistency)
スライダー 0〜10最小:Much lower/worse than usual最大:Much higher/better than usual
Q09
選択式

How does your pet typically react to veterinary visits?

  • Calm and relaxed
  • Mildly anxious
  • Very anxious or fearful
  • Aggressive or defensive
  • Varies a lot depending on the visit
Q10
選択式必須

Is your pet up to date on core vaccinations?

  • Yes, up to date
  • No, overdue
  • Not sure
  • Not applicable (e.g., indoor only)
Q11
AIインタビュー

If the respondent flagged a new symptom, injury, or ongoing condition, reconstruct the full picture: when it started, how it has changed, what triggers or worsens it, and anything the owner has already tried at home. Anchor on specific behaviors and timing rather than general impressions, and if the visit is wellness-only, instead ask what (if anything) has changed about the pet's routine, diet, or behavior since the last visit.

Q12
選択式

How would you describe your experience as a pet owner?

  • First-time pet owner
  • Experienced with this type of pet
  • Professional or breeder background
  • Prefer not to say
Q13
メッセージ

Thank you for sharing this information! Your responses will be added to your pet's chart so the veterinary team can prepare before your appointment.

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

  • Includes an AI follow-up interview that reconstructs the timeline and details of the pet's main symptom, so staff walk into the exam room already briefed instead of re-asking basics
  • Combines structured intake fields (animal type, age, vet visit history, current conditions, medications/allergies, vaccination status) with a slider matrix tracking recent changes in the pet's condition, giving both hard data and a symptom trendline
  • Captures owner context (visit reason, pet's typical reaction to vet visits, owner experience level) alongside clinical history, helping staff tailor handling for anxious animals or first-time owners
  • Free tier plus a transparent $50/mo Business plan for clinics that want the adaptive interview and auto-generated pre-visit reports, with no opaque enterprise-only pricing

SurveySparrow

Veterinary Patient History Form Template

A conversational-style, fielding-ready form for capturing a pet's basic history ahead of a visit. It's built on SurveySparrow's chat-like form UI, which is friendlier than a flat paper form but still a fixed question set. No mechanism to dynamically dig into a specific presenting symptom.

優れている点

  • Conversational one-question-at-a-time format that feels less clinical than a paper intake sheet
  • Ready to deploy as-is for basic patient history collection
  • Backed by a broader survey platform with reporting/dashboard features

物足りない点

  • Static question flow with no adaptive follow-up to probe a flagged symptom's timeline or severity
  • No automated quality scoring of open-text responses before staff review
  • No published methodology on how any AI-assisted features (if present) generate or score content

Jotform

Veterinary Emergency Intake Form Template

A drag-and-drop form template focused on emergency intake rather than routine new-patient history, useful for clinics needing fast triage paperwork. It's a static field set that owners fill out once, with no interview logic to reconstruct symptom history. Strong for form customization but not designed for pre-visit clinical briefing.

優れている点

  • Highly customizable form builder with widgets, e-signatures, and conditional logic for basic branching
  • Purpose-built for emergency/urgent scenarios, which may better fit walk-in clinics
  • Large template library so it can be adapted for many intake variants

物足りない点

  • No adaptive AI interview to reconstruct a symptom's onset, progression, or severity in the owner's own words
  • No per-response quality scoring, so incomplete or vague answers pass through unflagged
  • No auto-generated clinical summary/report for staff before the exam

Typeform

Veterinary Intake Form Template

A polished, conversational one-question-at-a-time intake form, consistent with Typeform's design-forward style. It collects standard pet and owner details but follows a fixed script for every respondent. There's no capability to branch into a deeper, personalized interview about a specific symptom.

優れている点

  • Clean, mobile-friendly conversational UI that likely improves completion rates
  • Simple logic jumps for basic conditional branching between questions
  • Easy embedding on clinic websites or booking confirmation emails

物足りない点

  • No adaptive AI follow-up interview to reconstruct symptom timelines beyond pre-set branching
  • No automated scoring of response quality or completeness for staff triage
  • No transparent prompt/methodology disclosure since there's no AI interview component

SurveyMonkey

Veterinarian Patient Intake Template

A short-form static survey covering essential new-patient intake fields, explicitly positioned as an abbreviated version for quick collection. It suits clinics wanting a fast, low-friction form rather than deep symptom exploration. Reporting is standard survey analytics, not a clinical pre-visit summary.

優れている点

  • Deliberately short format reduces owner drop-off and speeds up front-desk processing
  • Backed by SurveyMonkey's established survey analytics and export tools
  • Simple to customize field-by-field for a specific clinic's intake needs

物足りない点

  • No adaptive AI interview so the 'short form' can't expand into detail only when a symptom is flagged
  • No automated per-response quality scoring to flag vague or incomplete symptom descriptions
  • No auto-generated exam-ready report; results require manual review in survey dashboard

よくあるご質問

「New Patient Veterinary Intake & Health History 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：「Welcome! Before your pet's visit, we'd like to gather some background so the veterinary team is fully prepared. Your res…」・「What is the primary reason for today's visit?」・「What type of animal are you bringing in today?」。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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