Medical History Form
Collect the medical history before the appointment: current complaints, pre-existing conditions, medication, allergies, family and social history, plus consent.
Take the template with one click, adapt it to your project in a few minutes and start collecting answers.
Why this template
Adapted in minutes
Change, add or remove questions — the AI assistant rephrases them on request.
Free to start
Publish the template on a free account — no credit card and no trial clock.
Results in real time
Charts, filters and export to Excel, SPSS or CSV — with no extra work.
How to use this survey
- 1
Take the template
Create a free account and copy the template into your project with one click.
- 2
Adapt the questions
Adjust wording, scales and logic to your context — as often as you like.
- 3
Invite respondents
Share it by link, QR code, email or embedded on your website.
- 4
Analyse the answers
A live dashboard with charts, filters and export into your analysis tool.
The questions in this template
- What brings you to us?
- How long have you had these symptoms?
- How severe are your symptoms at the moment?
- Which conditions do you have, or have you had in the past?
- Since when do these conditions exist and how are they treated?
- Which operations or hospital stays have you had?
- Are you currently taking any medication regularly?
- Which medication are you taking?
- Are you taking anticoagulant medication?
- Do you have any known allergies or intolerances?
- How does your allergy or intolerance show itself?
- When were you last vaccinated against tetanus?
All 27 questions are fully editable.
Frequently asked questions
Is the “Medical History Form” template free?
Yes. You can use, customize and publish the template for free — a free account is all you need.
How do I use the “Medical History Form” template?
One click on “Use this template” creates it as your own survey in the editor. From there you can adapt it and share it by link, QR code, email or embedded on your own website.
Can I change, delete and add questions?
Completely. Once taken, the survey sits in your editor: every question, scale and answer option can be edited, reordered or removed.
What data does the “Medical History Form” template collect?
Which data you collect is decided question by question — if you don't ask for personal data, none is collected. Every question in the template can be changed or removed before you publish.
Are surveys built from the “Medical History Form” template secure and anonymous on empirio.ai?
Respondents need no account and simply open the link. Whether answers stay anonymous is up to the questions you ask: as long as nothing personal is asked, no answer can be traced back to a person.