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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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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

14 questions · ~7 min
Q01
Message

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
ConsentRequired

Please review and confirm before continuing.

Q03
Opinion ScaleRequired

Overall, how would you rate your health right now?

Scale: 1 – 10
Min:PoorMax:Excellent
Q04
Multiple ChoiceRequired

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
Long Text

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

Q06
Multiple Choice

Do you have any known allergies?

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

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
Multiple ChoiceRequired

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
Multiple ChoiceRequired

Which best describes your smoking history?

  • Never smoked
  • Former smoker (quit)
  • Current smoker - some days
  • Current smoker - daily
Q10
Multiple ChoiceRequired

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 Interview

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
Date

What is your date of birth?

Q13
Multiple Choice

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

  • Female
  • Male
  • Intersex
  • Prefer not to say
Q14
Message

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.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • 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.

What it does well

  • 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

Where it falls short

  • 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.

What it does well

  • 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

Where it falls short

  • 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.

What it does well

  • 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

Where it falls short

  • 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

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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