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Family Medical History & Personal Risk Awareness Survey

Captures which health conditions run in a patient's family, which relatives are affected, and how concerned the patient is about their own risk. Built for primary care, genetic counseling, or preventive health intake. An AI follow-up interview digs into the single most concerning condition — who had it, how severe, and whether it has already changed the patient's screening or lifestyle habits.

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샘플 질문

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질문 13개 · 약 7분
Q01
메시지

Thanks for taking a few minutes to share your family's health background. This helps your care team spot patterns that matter for your own health. Your responses are completely confidential and anonymized. It takes about 5 minutes, and you can skip anything you're unsure of.

Q02
객관식

Which of these blood relatives' medical history do you know reasonably well?

  • Mother
  • Father
  • Sibling(s)
  • Grandparent(s)
  • Aunts/Uncles
  • None of the above
Q03
매트릭스

For each condition, mark which of your blood relatives (that you know of) have had it.

8개 행 × 5개 열
  • Heart disease
  • High blood pressure
  • Diabetes
  • Cancer (any type)
  • Stroke
  • 외 3개
열: Mother · Father · Sibling(s) · Grandparent(s) · None that I know of
Q04
객관식필수

Of the conditions in your family, which one concerns you most for your own future health?

  • Heart disease
  • High blood pressure
  • Diabetes
  • Cancer
  • Stroke
  • A mental health condition
  • Alzheimer's or dementia
  • An autoimmune disease
Q05
AI 인터뷰

Explore the condition the respondent flagged as most concerning: which relative had it, roughly what age they were when it started, and how severe the outcome was. Find out whether knowing about it has changed the respondent's own health habits, screening schedule, or willingness to get tested. If they weren't sure of the details, ask what they'd want to find out and from whom.

Q06
의견 척도필수

How concerned are you about your own personal risk of developing this condition?

척도: 1 – 5
최소:Not at all concerned최대:Extremely concerned
Q07
객관식

In the last 12 months, have you discussed your family medical history with a doctor or other healthcare provider?

  • Yes
  • No
  • Not sure
Q08
객관식

Has a healthcare provider ever recommended genetic testing or earlier/more frequent screening based on your family history?

  • Yes
  • No
  • Not sure
Q09
장문형

Is there anything else about your family's medical history — conditions, ages, or details — that you think your care team should know?

Q10
객관식

What is your age range?

  • Under 18
  • 18-29
  • 30-44
  • 45-59
  • 60-74
  • 75+
  • Prefer not to say
Q11
객관식

What is your biological sex (relevant for some inherited conditions)?

  • Female
  • Male
  • Intersex
  • Prefer not to say
Q12
객관식

What is your race or ethnicity (some conditions vary in risk by ancestry)?

  • Black or African descent
  • East Asian
  • South Asian
  • Hispanic or Latino
  • Middle Eastern or North African
  • Native American or Indigenous
  • White
  • Multiple ethnicities
  • Prefer not to say
Q13
메시지

That's everything — thank you. Your responses will be added to your health record so your care team can flag any conditions worth watching or screening for early.

포함된 기능

  • AI 후속 질문

    정형화된 설문이 놓치는 세부 내용을, 주관식 답변에 맞춰 AI가 심층 질문으로 끌어냅니다.

  • 주의력 확인 장치

    성의 없는 답변과 저품질 응답자를 걸러내는 내장 안전장치입니다.

  • AI가 작성한 문안

    문구, 질문 순서, 분기 로직까지 AI가 연구 목표에 맞춰 작성합니다.

  • 자동 리포트

    응답이 모이면 주요 주제, 인용문, 이해하기 쉬운 요약이 자동으로 작성됩니다.

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이 템플릿을 선택하는 이유

  • Goes beyond a static family history checklist by using an AI follow-up interview to dig into the one condition the respondent flagged as most concerning — who had it, how severe, and whether it's already changed their screening or lifestyle habits
  • Pairs a relative-by-condition matrix with a personal concern rating (opinion scale) so you capture both objective family history and subjective risk perception in one flow
  • Includes intake-relevant screening questions (recent doctor discussions, genetic testing recommendations) plus age, sex, and ancestry fields relevant to inherited-condition risk
  • Every AI probe uses a transparent, reviewable prompt and produces an auto-generated report, with optional voice AI delivery for patients who prefer speaking over typing

Jotform

Family Medical History Form Template

A static, fillable form template for capturing family medical history, built on Jotform's drag-and-drop form builder. Good for basic intake paperwork but not designed to probe deeper into any single flagged condition. Best suited for practices wanting a simple, customizable PDF/web form rather than a conversational survey.

잘하는 점

  • Easy to customize fields via Jotform's form builder
  • Familiar form format for clinical intake staff
  • Can integrate with Jotform's broader forms/e-signature ecosystem

아쉬운 점

  • No adaptive follow-up questioning — it's a fixed set of fields
  • No automated per-response quality scoring or auto-generated interview reports
  • No voice AI interview option

SurveySparrow

Family Medical History Questionnaire Template

A conversational-style questionnaire template covering family medical history, benefiting from SurveySparrow's chat-like survey UI. It presents questions in a friendlier flow than a plain form, but questioning is still pre-scripted rather than adaptive to what the respondent flags as concerning. No indication of AI-driven follow-up probing on flagged conditions.

잘하는 점

  • Conversational, chat-style presentation improves respondent experience
  • Mobile-friendly survey format
  • Part of a broader survey platform with reporting/dashboard tools

아쉬운 점

  • No adaptive AI follow-up interview into the most concerning condition
  • No published methodology for how any AI features (if present) generate questions
  • No voice AI interview mode

SurveyMonkey

Medical History Form Template

A general medical history form template, broader than family-history-specific and geared toward standard patient intake. It's a static template within SurveyMonkey's survey builder, offering standard logic/skip patterns but no condition-specific probing. Useful as a generic intake baseline rather than a specialized family-risk assessment.

잘하는 점

  • Backed by SurveyMonkey's established survey infrastructure and analytics
  • Simple to deploy and distribute at scale
  • Supports standard skip logic for basic branching

아쉬운 점

  • No adaptive AI interview to explore the single most concerning condition in depth
  • No automated quality scoring of open-text responses
  • Broader medical-history focus, not tailored specifically to family risk/genetic counseling context

Typeform

Family Health History Questionnaire

A one-question-at-a-time family health history questionnaire using Typeform's signature conversational interface. It's visually polished and easy for respondents to complete, but its branching logic is pre-set rather than dynamically generated based on what the respondent identifies as most concerning. No adaptive interviewing or scoring layer.

잘하는 점

  • Clean, engaging one-question-at-a-time UX
  • Easy conditional logic for basic branching
  • Strong template design and completion-rate optimization

아쉬운 점

  • No adaptive AI follow-up interview or voice AI option
  • No automated per-response quality scoring
  • No auto-generated clinical/report summary of findings

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