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Healthcare & Clinical

Personal Health History Intake Survey

Captures a patient's current health status, chronic conditions, medications, allergies, family history, and lifestyle risk factors ahead of a visit — with an AI follow-up that reconstructs the real story behind their most significant condition or symptom instead of a checkbox. Built for clinics, telehealth intake, and health research teams standardizing pre-visit history collection.

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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14問・約7分
Q01
メッセージ

Welcome! Before your visit, we'd like to understand your health history so your care team is prepared. This takes about 5-6 minutes, and your answers are kept confidential.

Q02
同意必須

Please review and confirm before continuing.

Q03
オピニオンスケール必須

Overall, how would you rate your health right now?

スケール: 1 – 10
最小:Poor最大:Excellent
Q04
選択式必須

Have you ever been diagnosed with any of the following conditions?

  • High blood pressure
  • Diabetes (Type 1 or 2)
  • Heart disease
  • Asthma or COPD
  • Cancer (past or current)
  • Anxiety or depression
  • Arthritis
  • Thyroid disorder
Q05
自由回答（長文）

Please list any medications, supplements, or dosages you currently take regularly. Write 'None' if not applicable.

Q06
選択式

Do you have any known allergies?

  • Medication allergy
  • Food allergy
  • Environmental allergy (pollen, dust, pet dander)
  • Latex allergy
  • Insect sting allergy
Q07
選択式

Has an immediate family member (parent or sibling) been diagnosed with any of the following?

  • Heart disease
  • Diabetes
  • Cancer
  • High blood pressure
  • Stroke
  • Mental health condition
  • Alzheimer's or dementia
Q08
選択式必須

In the last 7 days, on how many days did you get at least 8 minutes of physical activity?

  • 0 days
  • 1-2 days
  • 3-4 days
  • 5-7 days
Q09
選択式必須

Which best describes your smoking history?

  • Never smoked
  • Former smoker (quit)
  • Current smoker - some days
  • Current smoker - daily
Q10
選択式必須

In the last year, how often have you had an alcoholic drink?

  • Never
  • Monthly or less
  • 2-4 times a month
  • 2-3 times a week
  • 4 or more times a week
Q11
AIインタビュー

Reference the respondent's self-rated overall health and any chronic conditions they selected. Ask them to walk through how the condition affects daily life, how well it's currently managed (medication, monitoring, specialist care), and any recent changes in symptoms or severity. If they reported no diagnosed conditions or excellent health, instead probe for any symptoms, aches, or changes they've noticed but haven't yet mentioned to a doctor, and why.

Q12
日付

What is your date of birth?

Q13
選択式

What was your sex assigned at birth? (Used for risk assessment purposes only.)

  • Female
  • Male
  • Intersex
  • Prefer not to say
Q14
メッセージ

Thank you for sharing this with us. Your history will be reviewed by your care team before your visit and stored securely as part of your confidential medical record.

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 checkbox history collection with an AI follow-up interview that reconstructs the real story behind the respondent's most significant condition or symptom, referencing their self-rated health and reported chronic conditions
  • Covers the full pre-visit intake picture in one flow: current conditions, medications/dosages, allergies, family history, physical activity, smoking and alcohol use, and demographic risk factors
  • Opens with a clear consent step and closes with a message confirming care-team review, giving patients a transparent, guided experience rather than a bare form
  • Produces an auto-generated report clinics or research teams can use to standardize pre-visit history without manual chart review

Typeform

Personal Training Health History Questionnaire

This is a fielding-ready conversational form aimed at personal trainers screening new clients, covering injuries, medications, and lifestyle basics before a training program. It's built for fitness intake rather than clinical or telehealth visit preparation, so its depth on chronic conditions, family history, and clinical risk factors is limited compared to a health-system-oriented intake. Useful as a lightweight model for conversational form flow, not for research-grade history capture.

優れている点

  • Simple, mobile-friendly conversational form format typical of Typeform
  • Quick to deploy for fitness/wellness intake use cases
  • Likely includes basic injury and medication questions relevant to training safety

物足りない点

  • Static question set with no adaptive follow-up probing into a client's most significant condition
  • Not designed for clinical intake depth (e.g., structured family history, allergy detail, per-visit summarization)
  • No published methodology for how responses are scored or synthesized into a clinician-ready summary

QuestionPro

Health History Survey Questions Template | Sample Survey, Examples, Questions & Questionnaires

This page reads as a sample-questions and best-practices guide for health history surveys rather than a single fielding-ready template, offering example question types researchers can copy into their own survey. It's a reasonable reference for question wording but requires manual assembly into a deployable instrument. There's no indication of adaptive interviewing or automated report generation built into the flow.

優れている点

  • Broad library of example health history question types to draw from
  • General survey platform with standard logic/branching capabilities
  • Positioned for research and general survey use cases, giving flexibility

物足りない点

  • Presented as example content/guide rather than a ready-to-field structured template
  • No adaptive AI follow-up to explore the story behind a significant condition
  • No transparent prompt methodology or automated per-response quality scoring

SurveySparrow

Dental Health History Questionnaire

This is a fielding-ready template scoped specifically to dental intake, covering relevant medical background a dentist needs before treatment. It's a genuine health history collection tool but narrowly scoped to oral/dental care rather than general primary care, telehealth, or population health research. Its conversational format is a plus, though it appears static rather than adaptive.

優れている点

  • Ready-to-use template tailored to a specific clinical context (dentistry)
  • Conversational, chat-style survey format consistent with SurveySparrow's platform
  • Likely includes standard consent and medical background fields relevant to dental treatment

物足りない点

  • Scoped to dental-specific history, not general chronic condition, family history, or lifestyle risk capture for primary/telehealth intake
  • No adaptive AI follow-up to reconstruct the narrative behind a patient's most significant condition
  • No automated quality scoring or auto-generated summary report for care teams

よくあるご質問

「Personal Health 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14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 history so your care team is prepared. This takes about…」・「Please review and confirm before continuing.」・「Overall, how would you rate your health right now?」。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、14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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