Q01
メッセージ
すべてのテンプレートHealthcare & Clinical
Personal Health Status & Wellbeing Evaluation
A whole-person health check-in covering self-rated health, energy, sleep, stress, symptom severity, and existing conditions — for clinics, employers, or wellness programs tracking how people are really doing. An AI follow-up interview digs into whatever symptom or condition the respondent flagged as most severe, uncovering impact and what they've already tried before their next visit.
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
Q02
選択式必須
Overall, how would you rate your health right now?
- Excellent
- Very good
- Good
- Fair
- Poor
Q03
オピニオンスケール必須
In the last 30 days, how would you rate your typical energy level?
スケール: 1 – 7
最小:Constantly exhausted最大:Full of energy
Q04
マトリクス必須
In the last 30 days, how often has each of the following been true for you?
4行 × 5列
- I got 7+ hours of restful sleep
- I was physically active for at least 20 minutes
- I ate balanced meals with vegetables or fruit
- I felt able to manage day-to-day stress
列: Never · Rarely · Sometimes · Often · Always
Q05
スライダーマトリクス必須
Right now, how severe is each of the following for you?
4行（各行にスライダー1つ）
- Physical pain or discomfort
- Anxiety or worry
- Low mood or sadness
- Sleep difficulties
スライダー 0〜10最小:None at all最大:Severe
Q06
選択式
Do you currently have any of the following diagnosed health conditions?
- High blood pressure
- Diabetes
- Heart disease
- Asthma or a lung condition
- Anxiety or depression
- Arthritis or a joint condition
Q07
評価スケール必須
How satisfied are you with your current overall health?
範囲: 1 – 5
最小:Not at all satisfied最大:Extremely satisfied
Q08
AIインタビュー
Identify whichever symptom or condition the respondent rated as most severe or flagged in their health history, and probe it in depth: how long it's been going on, how it affects daily life or work, what (if anything) they've already tried, and whether it's getting better, worse, or staying the same. If nothing stood out as severe, ask what one change would most improve their day-to-day health and why they haven't made it yet.
Q09
選択式
Which of these make it hardest for you to maintain healthy habits?
- Lack of time
- Cost
- Lack of motivation
- Pain or physical limitation
- Lack of support from others
- Stress or mental health
- Limited access to healthy food or exercise options
Q10
自由回答（長文）
Is there anything else about your health you'd like your care team to know before your next visit?
Q11
プルダウン
What is your age range? (Optional)
- Under 18
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65-74
- 75+
- Prefer not to say
Q12
選択式
What is your gender? (Optional)
- Woman
- Man
- Non-binary
- Prefer not to say
Q13
メッセージ
Thank you for sharing this with us. Your responses will be reviewed alongside your health record to help personalize your care and flag anything that needs follow-up.
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 a full whole-person snapshot in one flow — self-rated health, energy, sleep/stress frequency (matrix), and a slider matrix for symptom severity — not just a single satisfaction score.
- The AI follow-up interview automatically identifies whichever symptom or condition the respondent flagged as most severe and probes for impact and what they've already tried, something a static form template can't do.
- Captures practical context (barriers to healthy habits, open-ended notes for the care team, optional age/gender) so clinics or wellness programs get both structured data and narrative detail before a visit.
- Every response can be reviewed alongside auto-generated reports, with transparent prompts showing exactly how the AI follow-up was framed — no black-box scoring.
Jotform
Health Evaluation Form TemplateA ready-to-use, fielding-ready form template for general health evaluations, built on Jotform's drag-and-drop form builder. It's a solid starting point for collecting standard health intake fields but is a static questionnaire rather than an interactive interview. Customization is easy, but any follow-up on flagged symptoms would need to be manually scripted with conditional logic.
優れている点
- Familiar, easy-to-customize drag-and-drop form builder
- Fielding-ready template that can be deployed quickly
- Part of a broader ecosystem (integrations, e-signatures, file uploads) useful for clinical intake
物足りない点
- No adaptive AI follow-up — any deeper probing requires manually built conditional logic, not a real interview
- No automated per-response quality scoring or auto-generated respondent reports
- No transparent prompt methodology since there's no AI interviewing layer at all
Typeform
Health Evaluation Form TemplateA conversational, one-question-at-a-time health evaluation template designed for a pleasant respondent experience. It's fielding-ready and benefits from Typeform's polished UI and branching logic, but it remains a fixed question set rather than a true adaptive interview. There's no mechanism to dynamically dig into whichever symptom a respondent rates as most severe.
優れている点
- Clean, conversational UI that tends to improve completion rates
- Built-in logic jumps for basic personalization between questions
- Fielding-ready template usable out of the box
物足りない点
- No AI-driven follow-up interview — logic jumps are pre-set branches, not adaptive probing based on response content
- No automated quality scoring of individual responses
- No voice AI interview option or auto-generated clinical-style reports
よくあるご質問
「Personal Health Status & Wellbeing Evaluation」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 for this health check-in. Your responses are completely confidential and anonymized. The…」・「Overall, how would you rate your health right now?」・「In the last 30 days, how would you rate your typical energy level?」。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。
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