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Patient Health Data Sharing & Privacy Survey Template

Measure patient trust, consent, and sharing preferences for health data across providers, insurers, and apps. Use this template to inform privacy and compliance.

What's Included

AI-Powered Questions

Intelligent follow-up questions based on responses

Automated Analysis

Real-time sentiment and insight detection

Smart Distribution

Target the right audience automatically

Detailed Reports

Comprehensive insights and recommendations

Sample Survey Items

Q1
chat message
Welcome! This brief survey takes about 5–7 minutes. Please answer honestly; your responses are confidential.
Q2
multiple choice
In the last 12 months, did you visit any health professional (e.g., doctor, nurse, therapist)?
  • Yes
  • No
Q3
multiple choice
Do you currently have health insurance coverage?
  • Yes
  • No
  • Prefer not to say
Q4
multiple choice
In the last 12 months, which of these health or wellness tools did you use? Select all that apply.
  • Fitness/activity tracker (e.g., Fitbit, Apple Watch)
  • Nutrition or calorie app
  • Symptom checker or health chatbot
  • Medication reminder app
  • Telemedicine/virtual care platform
  • Patient portal (e.g., MyChart)
  • Sleep tracking app/device
  • Mental health app
Options randomized
Q5
opinion scale
Overall, how comfortable are you with sharing your health information with medical providers?
Q6
multiple choice
During your most recent visit, how did you share information with your provider? Select all that apply.
  • Spoke in person
  • Filled paper forms
  • Phone call
  • Email
  • Online portal
  • Synced data from a wearable/app
  • I don't recall
Options randomized
Q7
opinion scale
How comfortable are you with sharing health information with your health insurer?
Q8
multiple choice
In the last 12 months, did you share any health data directly with your insurer?
  • Yes — through claims only
  • Yes — via a wellness program
  • Yes — by connecting an app or device
  • Not sure
  • No
Q9
matrix
How comfortable are you with sharing data with each of these digital services?
Q10
short text
Name one health app or device you used most recently.
Max 100 chars
Q11
multiple choice
Attention check: To confirm you are paying attention, please select “No.”
  • Yes
  • No
Q12
ranking
Please rank these data types from most to least comfortable to share.
Q13
rating
How important is being able to control who can see your health data?
Q14
long text
Do you have any final comments or context you would like to share about health data sharing?
Max 600 chars
Q15
ai interview
AI Interview: 2 Follow-up Questions on health data sharing
AI Interview
Q16
dropdown
What is your age?
Q17
multiple choice
Which best describes your gender?
  • Man
  • Woman
  • Non-binary
  • Prefer not to say
Q18
dropdown
Where do you currently live?
Q19
dropdown
What is the highest level of education you have completed?
Q20
multiple choice
What is your current employment status?
  • Employed full time
  • Employed part time
  • Self-employed
  • Student
  • Homemaker
  • Unemployed
  • Retired
  • Prefer not to say
Q21
chat message
Thank you for participating! Your responses have been recorded.

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Patient Health Data Sharing & Privacy Survey Template - Survey Template | QuestionPunk