Q01
Message
All templates
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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
Q02
Multiple Choice
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
Matrix
For each condition, mark which of your blood relatives (that you know of) have had it.
8 rows × 5 columns
- Heart disease
- High blood pressure
- Diabetes
- Cancer (any type)
- Stroke
- +3 more
Columns: Mother · Father · Sibling(s) · Grandparent(s) · None that I know of
Q04
Multiple ChoiceRequired
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 Interview
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
Opinion ScaleRequired
How concerned are you about your own personal risk of developing this condition?
Scale: 1 – 5
Min:Not at all concernedMax:Extremely concerned
Q07
Multiple Choice
In the last 12 months, have you discussed your family medical history with a doctor or other healthcare provider?
- Yes
- No
- Not sure
Q08
Multiple Choice
Has a healthcare provider ever recommended genetic testing or earlier/more frequent screening based on your family history?
- Yes
- No
- Not sure
Q09
Long Text
Is there anything else about your family's medical history — conditions, ages, or details — that you think your care team should know?
Q10
Multiple Choice
What is your age range?
- Under 18
- 18-29
- 30-44
- 45-59
- 60-74
- 75+
- Prefer not to say
Q11
Multiple Choice
What is your biological sex (relevant for some inherited conditions)?
- Female
- Male
- Intersex
- Prefer not to say
Q12
Multiple Choice
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
Message
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.
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 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 TemplateA 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.
What it does well
- 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
Where it falls short
- 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 TemplateA 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.
What it does well
- Conversational, chat-style presentation improves respondent experience
- Mobile-friendly survey format
- Part of a broader survey platform with reporting/dashboard tools
Where it falls short
- 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 TemplateA 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.
What it does well
- Backed by SurveyMonkey's established survey infrastructure and analytics
- Simple to deploy and distribute at scale
- Supports standard skip logic for basic branching
Where it falls short
- 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 QuestionnaireA 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.
What it does well
- Clean, engaging one-question-at-a-time UX
- Easy conditional logic for basic branching
- Strong template design and completion-rate optimization
Where it falls short
- No adaptive AI follow-up interview or voice AI option
- No automated per-response quality scoring
- No auto-generated clinical/report summary of findings
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.