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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.

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샘플 질문

템플릿에 포함된 내용을 미리 확인해 보세요. 모든 질문은 설문 공개 전에 자유롭게 수정할 수 있습니다.

질문 16개 · 약 8분
Q01
메시지

Welcome! Before your visit, we'd like to understand your health background so your care team is prepared. This takes about 6-8 minutes, and your answers stay in your confidential medical record.

Q02
객관식필수

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
장문형

Please list any current or past surgeries or hospitalizations, including approximate dates.

Q04
매트릭스

For each medication you currently take, how consistently do you take it as prescribed?

3개 행 × 5개 열
  • Medication 1
  • Medication 2
  • Medication 3
열: Always as prescribed · Usually · Sometimes · Rarely · Not currently taking
Q05
객관식필수

Do you have any known drug, food, or environmental allergies?

  • No known allergies
  • Yes, drug allergy
  • Yes, food allergy
  • Yes, environmental allergy
Q06
장문형

If you selected an allergy above, describe the reaction you experienced (e.g., rash, swelling, difficulty breathing).

Q07
객관식필수

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
객관식필수

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
객관식

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
의견 척도필수

Over the past 2 weeks, how would you rate your overall physical health?

척도: 1 – 5
최소:Very poor최대:Excellent
Q11
AI 인터뷰

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
메시지

Thanks for sharing this information. Just a few quick background questions to finish.

Q13
숫자

What is your age?

Q14
객관식

What is your sex assigned at birth?

  • Female
  • Male
  • Intersex
  • Prefer not to say
Q15
객관식

What is your current insurance status?

  • Private insurance
  • Medicare/Medicaid
  • Uninsured
  • Other
  • Prefer not to say
Q16
메시지

All done — thank you. Your responses will be added to your confidential medical record and reviewed by your care team before your visit.

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.

다른 서비스와 비교

다른 설문 도구의 가장 유사한 템플릿을 검토했습니다. 그 도구들이 잘하는 점과, 이 템플릿이 한발 더 나아가는 지점을 정리했습니다.

이 템플릿을 선택하는 이유

  • 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.

잘하는 점

  • 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

아쉬운 점

  • 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 Template

A 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.

잘하는 점

  • 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

아쉬운 점

  • 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 Template

A 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.

잘하는 점

  • Backed by SurveyMonkey's established analytics and reporting suite
  • Broad template library and familiar respondent experience
  • Straightforward setup for standard medical history capture

아쉬운 점

  • 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 Template

A 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.

잘하는 점

  • Chat-style conversational format similar to messaging apps
  • Focused specifically on family history collection
  • Likely offers branching logic for basic personalization

아쉬운 점

  • 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

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