Family health history questionnaire

Family Health HistoryBefore we get started, what's your name?and could you tell us your date of birth?Have you ever suffered from any of the following illnesses?

Asthma, Cancer, Dementia, Diabetes, Heart disease, Stroke

Have any family members suffered from the following illnesses? Please tick the relevant boxes.

Asthma

Cancer

Dementia

Diabetes

Heart disease

Stroke

Have any family members suffered from the following illnesses? Please tick the relevant boxes.

Asthma

Cancer

Dementia

Diabetes

Heart disease

Stroke

Please leave your phone number in case we need to follow up with youThanks, {{field:81011894-06e3-488b-a36f-ebadd31d042c}}. All received.

Collect up to 3.5x more data with Typeform

A simpler way to collect and organize patients’ data

Using an online questionnaire takes the manual effort out of collecting data. No more typing up information from paper forms. Use a family health history questionnaire to get the medical data you need and export it into a tidy spreadsheet in a click.

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Change text, colors, and even logos to match the look and feel of your brand. Then embed forms smoothly onto web and email.

Make forms feel effortless to fill out. Pace questions, call people by their name, and adapt the flow based on the data they share.

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Family health history questionnaire FAQs:

Typically, family health history questionnaires are used to collect medical data from patients about high-risk illnesses that might run in the family. Our matrix question type is perfect for collecting information about multiple family members on the same page, saving your patients time. You can ask questions about your patient too, to find out how their medical history matches up and where possible risks might lie.

A family health history questionnaire or family medical history form can be used to identify possible at-risk patients. This data can inform you of recurring illnesses in a family, so you know when to flag up patients for additional tests. It’s also valuable to have this information on file, in case problems crop up later on. Typeforms make it easy to manage data now and in the future, with easily exportable data and integrations with other apps so you can send your results where you need them.

Before you send out your form, there are two things you should do:

Set up a BAA (Business Associate Agreement) with us

Typeform is a HIPAA-compliant company, so all the healthcare-related info you process with us is legally airtight. But for you to be 100% HIPAA compliant, you’ll first need to set up a BAA. To do this you would need to talk to us about our enterprise plan, which you can do by filling out this Typeform, or contacting your Typeform account manager.

Check the local data collection laws

Data collection laws aren’t a one-size-fits-all thing—especially when there’s sensitive medical info involved. So before hitting share, seek advice from a local lawyer to make sure you’ve covered everything.