Q01
メッセージ
すべてのテンプレートHealthcare & Clinical
Patient Medical History Intake Survey
Captures a new or returning patient's health background, current medications, allergies, and family history before a clinical visit, with an AI follow-up that clarifies vague or incomplete symptom and condition details so clinicians get a fuller picture without a rushed in-office conversation.
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
選択式必須
Which of the following conditions have you ever been diagnosed with?
- High blood pressure
- Diabetes
- Heart disease
- Asthma or lung disease
- Cancer
- Depression or anxiety
- Thyroid disorder
- None of these
Q03
自由回答（長文）
Please list any current or past surgeries or hospitalizations, including approximate dates.
Q04
マトリクス
For each medication you currently take, how consistently do you take it as prescribed?
3行 × 5列
- Medication 1
- Medication 2
- Medication 3
列: Always as prescribed · Usually · Sometimes · Rarely · Not currently taking
Q05
選択式必須
Do you have any known drug, food, or environmental allergies?
- No known allergies
- Yes, drug allergy
- Yes, food allergy
- Yes, environmental allergy
Q06
自由回答（長文）
If you selected an allergy above, describe the reaction you experienced (e.g., rash, swelling, difficulty breathing).
Q07
選択式必須
Have any of your immediate family members (parents, siblings, children) been diagnosed with heart disease, diabetes, cancer, or a genetic condition?
- Yes
- No
- Not sure
Q08
選択式必須
In the last 30 days, how often did you use tobacco products?
- Not at all
- 1-5 days
- 6-15 days
- 16-29 days
- Daily
Q09
選択式
In the last 30 days, how many days per week on average did you have an alcoholic drink?
- 0 days
- 1-2 days
- 3-4 days
- 5-6 days
- Every day
Q10
オピニオンスケール必須
Over the past 2 weeks, how would you rate your overall physical health?
スケール: 1 – 5
最小:Very poor最大:Excellent
Q11
AIインタビュー
Probe any condition, symptom, or medication the respondent flagged as ongoing or unclear, especially any diagnosis marked in the condition checklist or allergy question. Ask when it started, how it's currently managed or treated, whether it's under control, and whether anything has changed recently. If they reported a low overall health rating, gently explore what's driving that and whether it relates to a condition already mentioned or something new.
Q12
メッセージ
Thanks for sharing this information. Just a few quick background questions to finish.
Q13
数値
What is your age?
Q14
選択式
What is your sex assigned at birth?
- Female
- Male
- Intersex
- Prefer not to say
Q15
選択式
What is your current insurance status?
- Private insurance
- Medicare/Medicaid
- Uninsured
- Other
- Prefer not to say
Q16
メッセージ
All done — thank you. Your responses will be added to your confidential medical record and reviewed by your care team before your visit.
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 step that specifically probes any condition, symptom, or medication the patient flagged as ongoing or unclear — reducing rushed in-office clarification.
- Combines structured clinical data capture (diagnosed conditions, surgeries/hospitalizations, medication adherence via a matrix question, allergies and reactions, family history) with adaptive conversational depth.
- Captures lifestyle and risk factors (tobacco use, alcohol frequency, self-rated physical health) alongside demographic and insurance details in one guided flow.
- Opens and closes with clear chat-based framing so patients understand the purpose and next steps, ending in an auto-generated summary for the clinical record.
Jotform
New Client Intake and Medical History Form (HIPAA)A fielding-ready static form template aimed at HIPAA-conscious intake, covering standard client and medical history fields. It's built for form-filling rather than conversational data gathering, and customization relies on Jotform's drag-and-drop builder rather than adaptive logic.
優れている点
- HIPAA-oriented positioning for healthcare use cases
- Established drag-and-drop form builder with wide template library
- Likely supports e-signature and file upload fields common to intake forms
物足りない点
- No adaptive AI follow-up to clarify vague symptom or condition entries
- No per-response quality scoring
- No published methodology for how clinical nuance is captured beyond static fields
Typeform
Patient Medical History Form TemplateA fielding-ready, single-question-at-a-time template well-suited to patient history collection, benefiting from Typeform's clean conversational UI. However, its branching logic is pre-set and can't dynamically probe unclear answers in real time the way an AI interview can.
優れている点
- Polished conversational one-question-per-screen UI likely improves completion rates
- Simple template structure suited to non-technical clinic staff setup
- Mobile-friendly design common to Typeform forms
物足りない点
- No adaptive AI follow-up for incomplete or vague symptom/condition answers
- No automated quality scoring of responses
- No voice AI interview option
SurveyMonkey
Medical History Form TemplateA fielding-ready static survey template from a broadly trusted survey platform, likely paired with SurveyMonkey's standard analytics and reporting tools. It covers general medical history capture but, like other form builders, lacks any mechanism to dynamically clarify ambiguous responses.
優れている点
- Backed by SurveyMonkey's established analytics and reporting suite
- Broad template library and familiar respondent experience
- Straightforward setup for standard medical history capture
物足りない点
- No adaptive AI follow-up interview to clarify vague symptom or medication details
- No automated per-response quality scoring
- No transparent prompt methodology since there's no AI interview layer
SurveySparrow
Family Medical History Questionnaire TemplateA fielding-ready conversational-style template, but its scope is narrower — focused specifically on family medical history rather than a full pre-visit patient intake covering current medications, allergies, and personal history. Like other builders here, it relies on static logic rather than adaptive AI clarification.
優れている点
- Chat-style conversational format similar to messaging apps
- Focused specifically on family history collection
- Likely offers branching logic for basic personalization
物足りない点
- Narrower scope than a full patient intake — doesn't cover current medications, personal surgical history, or insurance/demographics in one flow
- No adaptive AI follow-up to probe ongoing or unclear conditions
- No automated response quality scoring or voice AI interview option
よくあるご質問
「Patient Medical History Intake 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16問含まれており、最初の設問は次のとおりです：「Welcome! Before your visit, we'd like to understand your health background so your care team is prepared. This takes abo…」・「Which of the following conditions have you ever been diagnosed with?」・「Please list any current or past surgeries or hospitalizations, including approximate dates.」。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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