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?
Range: 1 – 10
Min: Not at all comfortableMid: NeutralMax: Extremely comfortable
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?
Range: 1 – 10
Min: Not at all comfortableMid: NeutralMax: Extremely comfortable
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?
Rows
Very uncomfortable
Uncomfortable
Neutral
Comfortable
Very comfortable
Fitness/activity trackers
•
•
•
•
•
Wellness/lifestyle apps
•
•
•
•
•
Telehealth platforms
•
•
•
•
•
Hospital/clinic patient portals
•
•
•
•
•
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.
Drag to order (top = most important)
Basic profile (age/sex)
Step counts/activity minutes
Heart rate or sleep data
Medication list
Lab results
Mental health notes or assessments
Genetic/ancestry data
Q13
Rating
How important is being able to control who can see your health data?
Scale: 11 (star)
Min: Not importantMax: Very important
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 InterviewLength: 2Personality: [Object Object]Mode: Fast
Reference questions: 12
Q16
Dropdown
What is your age?
18–24
25–34
35–44
45–54
55–64
65+
Prefer not to say
Q17
Multiple Choice
Which best describes your gender?
Man
Woman
Non-binary
Prefer not to say
Q18
Dropdown
Where do you currently live?
Africa
Asia
Europe
North America
South America
Oceania
Prefer not to say
Q19
Dropdown
What is the highest level of education you have completed?
Less than high school
High school or equivalent
Some college/Associate
Bachelor’s degree
Graduate or professional degree
Trade/Vocational
Prefer not to say
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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