Healthcare & Clinical

Pre-Visit Patient Intake & Symptom Screening Survey

Collects chief complaint, symptom severity, medical history, and current medications before an appointment so clinicians walk in prepared. An AI follow-up interview reconstructs the timeline and context behind the patient's main concern — onset, triggers, and what's already been tried — that a checkbox history alone can't capture.

このテンプレートを使うほかのテンプレートを見る

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15問・約8分

Q01

メッセージ

Welcome! Before your visit, we'd like to gather some background on how you've been feeling. Your responses are completely confidential and anonymized. This takes about 8 minutes and helps your care team make the most of your appointment time.

Q02

同意必須

Please review before continuing.

Q03

自由回答（短文）必須

In your own words, what is the main reason for your visit today?

Q04

選択式必須

How long have you been experiencing this main issue?

Less than 24 hours
A few days
About a week
Several weeks
A month or more
This is an ongoing/chronic issue

Q05

オピニオンスケール必須

On a scale of 0 to 10, how would you rate your pain or discomfort right now?

スケール: 0 – 10

最小:No pain最大:Worst pain imaginable

Q06

マトリクス必須

Over the past week, how severe have the following symptoms been? (Template note: replace this list with the symptom set relevant to your specialty before launching.)

5行 × 4列

Fatigue
Fever or chills
Nausea or vomiting
Shortness of breath
Dizziness or lightheadedness

列: None · Mild · Moderate · Severe

Q07

選択式必須

Do you currently have, or have you ever been diagnosed with, any of the following? (Template note: swap in the condition list your practice screens for.)

Diabetes
High blood pressure
Heart disease
Asthma or lung disease
Kidney disease
Cancer (past or present)
Autoimmune condition

Q08

自由回答（長文）

Please list all medications, vitamins, and supplements you currently take, including dose and frequency if known.

Q09

自由回答（短文）必須

Do you have any known allergies (medications, foods, or environmental)? If none, please write 'None.'

Q10

評価スケール必須

How much is this issue interfering with your daily activities (work, sleep, family, etc.)?

範囲: 1 – 5

最小:Not at all最大:Completely

Q11

AIインタビュー

Reconstruct the story behind the patient's main complaint: when it started, how it has changed since then, what makes it better or worse, and what (if anything) they've already tried, including over-the-counter remedies. If they rated their pain or interference high, probe concretely on how it's affecting a specific recent day. If their answers are vague or minimize severity, gently ask for a specific recent example.

Q12

メッセージ

Almost done — just a couple of background questions. These are optional and help us keep accurate records.

Q13

日付

What is your date of birth?

Q14

選択式

What is your gender identity?

Male
Female
Non-binary
Prefer to self-describe
Prefer not to say

Q15

メッセージ

Thank you for sharing this with us. Your responses will be added to your chart and reviewed by your care team before your appointment so we can make the most of your time together.

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: an AI follow-up interview reconstructs the timeline behind the chief complaint — onset, triggers, and what's already been tried — so clinicians walk in with context, not just a symptom list.
Combines structured clinical data (symptom severity matrix, pain rating, medication list, allergy check, medical history) with a conversational layer that adapts to each patient's actual answers.
Uses a consent step and clear chat-style framing to set expectations before collecting sensitive health information, and closes with a message confirming responses will be added to the chart.
Separates optional demographic questions (date of birth, gender identity) from clinical questions, reducing friction on the medically essential parts of the intake.

Jotform

Medical Patient Intake Form Template

A standard fielding-ready form for collecting patient demographics, history, and reason for visit. It's built for quick data capture and integrates with Jotform's broader form ecosystem (e-signatures, file uploads), but it is a static questionnaire rather than an interview. Good for basic intake paperwork, less suited to capturing nuance around a patient's symptom story.

優れている点

Established, widely-used form builder with strong customization and integration options
Likely supports e-signature and file upload fields useful for intake paperwork
Simple to deploy and embed on a clinic website or patient portal

物足りない点

Static form fields only — no adaptive follow-up questioning to explore onset, triggers, or prior treatment attempts
No per-response quality scoring or automated report generation for clinicians
No transparent, published methodology for how questions are structured or scored

Typeform

Appointment Request Form Template

This is primarily an appointment-request/scheduling form with intake fields layered in, styled in Typeform's conversational one-question-at-a-time format. It's polished and easy for patients to complete, but it's a fixed script — it doesn't ask context-aware follow-ups. It reads more as a booking + basic-intake hybrid than a deep symptom-screening tool.

優れている点

Clean, mobile-friendly conversational form design that patients find easy to complete
Combines appointment scheduling with basic intake in one flow
Strong brand reputation for form completion rates and UX polish

物足りない点

No adaptive AI interviewing — every patient sees the same fixed question sequence regardless of their answers
No mechanism to reconstruct symptom timeline, triggers, or prior treatments beyond what's explicitly asked
No automated quality scoring or clinician-facing report generation built for clinical intake

よくあるご質問