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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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Sample questions

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

16 questions · ~8 min
Q01
Message

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
Multiple ChoiceRequired

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
Long Text

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

Q04
Matrix

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

3 rows × 5 columns
  • Medication 1
  • Medication 2
  • Medication 3
Columns: Always as prescribed · Usually · Sometimes · Rarely · Not currently taking
Q05
Multiple ChoiceRequired

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

  • No known allergies
  • Yes, drug allergy
  • Yes, food allergy
  • Yes, environmental allergy
Q06
Long Text

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

Q07
Multiple ChoiceRequired

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
Multiple ChoiceRequired

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
Multiple Choice

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
Opinion ScaleRequired

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

Scale: 1 – 5
Min:Very poorMax:Excellent
Q11
AI Interview

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
Message

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

Q13
Number

What is your age?

Q14
Multiple Choice

What is your sex assigned at birth?

  • Female
  • Male
  • Intersex
  • Prefer not to say
Q15
Multiple Choice

What is your current insurance status?

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

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

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

  • 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.

What it does well

  • 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

Where it falls short

  • 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.

What it does well

  • 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

Where it falls short

  • 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.

What it does well

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

Where it falls short

  • 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.

What it does well

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

Where it falls short

  • 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

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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