3 minutes to complete
To complete the Personal Health History Questionnaire, individuals must be over the age of 18, able to provide accurate and detailed information about their medical history, and have the cognitive ability to understand and answer the questions. It is important to disclose any relevant medical conditions or family history for an accurate assessment.
Have you had any major surgeries or hospitalizations in the past?
Do you have any chronic medical conditions such as diabetes, hypertension, asthma, or heart disease?
Have you ever been diagnosed with any mental health conditions such as depression or anxiety?
Have you ever been diagnosed with any infectious diseases such as tuberculosis or hepatitis?
Do you have any allergies to medications or food?
Do you smoke or use tobacco products?
Do you consume alcohol?
Do you exercise regularly?
Has anyone in your immediate family been diagnosed with any chronic medical conditions or mental health conditions?
List all current medications you are taking including prescription drugs, over-the-counter medications, and supplements:
Is there anything else you would like us to know about your health history?
What is your height and weight?
When was your last physical examination?
Have you had any recent vaccinations? If yes, please specify:
BlockSurvey puts privacy and security above anything else. The integration of blockchain technology is not a gimmick as in many products; it's a core feature enabling privacy and security. The survey building tools are impeccable. I've used numerous SaaS survey tools, and nothing comes close.
This platform goes far beyond basic surveys. I’ve used it for lead generation, landing page enrichment, and even embedded videos. Everything’s easy to use, well documented, and super flexible—whether you're building forms, quizzes, or something more advanced.
Uses blockchain technology that allows users to create survey forms where data is secure and private. UI looks very beautiful.
For our NGO, data privacy is everything—and this platform nails it. It keeps personal info fully protected while letting us design beautiful, chat-like surveys that increase engagement. Team collaboration features sealed the deal.
From blockchain-level security and AI-generated questions to powerful logic flows and white-label domains, BlockSurvey has it all. It’s secure, innovative, and packed with features like calculations, templates, and in-app analytics. I use it to create personalized assessments for leadership training—nothing else compares.
BlockSurvey is very user-friendly with amazing customization options. It makes capturing data simple and secure. While the Web3 space still has room to mature, the platform itself is smooth and intuitive.
Creating surveys with BlockSurvey has been a breeze. The drag-and-drop interface is intuitive, and we’re able to collect data anonymously and securely—without intermediaries. It’s interactive, friendly, and encourages high participation while protecting user privacy. The reports are solid, and we’ve used it confidently for internal and external feedback.
Few tools combine data confidentiality and form aesthetics like this one. The conversational design improved my response rate by 43%, and the webhook integrations made syncing to our CRM effortless. I also love how responsive and community-driven the support team is.
I think BlockSurvey is good for short and long surveys. What I find the best is the fact that there are so many templates I can use and customize.
