Medical History Form

Afwijkend factuuradres?

Is er bij u ooit een operatie aan maag, darmen, hart of longen uitgevoerd?

Heeft u een chronische, besmettelijke aandoening ? 

Gebruikt u medicatie die de bloedstolling beïnvloedt of slaapmedicatie, laxeermiddelen, bloeddrukverlagende medicijnen of anticonceptie? 

Heeft u een bloedingziekte, bloedarmoede of een erfelijke stollingsziekte in de familie?

Bent u bekend met een vorm van een allergische reactie of overgevoeligheid ?

Zijn er bij u stofwisselingsaandoeningen bekend?

A calculated field is the starting point of your calculations. Define the dynamic value you want to calculate (for example score, price, or lead status) and use conditional logic to select the operations you want to perform (add, subtract, multiply, divide, assign or concatenate values). <a href='{{link}}' target='_blank'>Learn more</a>.

Protect your form from spam & bots with reCAPTCHA. Add this block just above your Submit button. <a href='{{link}}' target='_blank'>Learn more</a>.

Use this to offer a range of answers to a question. Respondents can select multiple answers.

Create smart forms based on your respondents' input. Jump to a page, calculate dynamic values, hide specific blocks and require answers. <a href='{{link}}' target='_blank'>Learn more</a>.

Add a divider to separate sections in your form.

Use this for a long list of answer options, like selecting your nationality.

Embed any online content: Google Maps, Calendly, GitHub Gist, online PDFs, Tweets, Figma files and more.

Embed audio from SoundCloud, Spotify, .MP3s and more. Insert this embed block and paste the audio URL or embed link.

Embed video’s from YouTube, Vimeo, Loom, .MP4s and more. Insert this embed block and paste the video’s URL or embed link.

Use this to collect files, like a portfolio or resume.

Big heading suitable for a title of main sections in your form.

Medium heading suitable for a title of smaller sections in your form.

Send custom data from your form link to your form submissions via URL query string parameters. <a href='{{link}}' target='_blank'>Learn more</a>.

Upload an image, add an image URL, or choose from Unsplash. Use images to visualize products or to personalize your form with your visual style.

Use this to allows respondents to pick a date in this format: Month Day, Year.

Use this to collect correctly formatted email addresses as answers. If someone tries to add text in the wrong format, they will have to try again.

Use this to collect correctly formatted links or websites.

Use this if you want a number as a response. Add a minimum and/or maximum number limit.

Use this to collect correctly formatted phone numbers.

Use this for short text answers. Add an answer label or placeholder text for guidance.

Use this to allow respondents to pick a time in this format: XX:XX

Add a text label to an input field and explain what type of answer you expect.

Use this for numeric answers on a scale, to measure client satisfaction for example. Adjust the scale size and add a scale label on the left, center and/or right.

Use this to group similar questions with the same answer options, where each question can be single or multiple select. This is useful when asking multiple questions with the same rating scale.

Use this to offer a range of answer options. Respondents can only choose one answer.

Use this to allow users to select multiple answers from a list of choices.

Add a new page to your form. Use this to create multi-step forms, or to create a custom Thank You page.

Use this to sell products and accept payments securely via Stripe (fees may apply). <a href='{{link}}' target='_blank'>Learn more</a>.

Use this to add a question title and input field at the same time.

Use this to rank options in order of preference or importance. Respondents can drag and drop the options into the desired order.

Use this for a simple and visual way of rating things. Get to know your customers’ opinions about your product or service for example.

Detect the respondent’s country automatically based on their IP address. The country will appear in the submission data without storing or tracking any personal information.

Use this to collect electronic signatures for business contracts, agreements, waivers, etc. <a href='{{link}}' target='_blank'>Learn more</a>.

Use this to display any type of text. You can format it as you want and customize it to your needs.

Use this for long form answers without character limits.

Add a ‘Thank you’ page to your form. This is the page your respondents will see after submitting the form.

Add a title to a question in your form. For example: ‘Ready to join our team’ as a part of an application form.

Use this to effortlessly collect wallet addresses with Wallet Connect, providing a seamless and secure connection with the most popular crypto wallets.

Calculated fields

reCAPTCHA

Checkboxes

Conditional logic

Divider

Dropdown

Embed anything

Audio

Video

File upload

Heading 1

Heading 2

Heading 3

Hidden fields

Image

Date

Email

Link

Number

Phone number

Short answer

Time

Label

Linear scale

Matrix

Multiple choice

Multi-select

New page

Payment

Question

Ranking

Rating

Respondent's country

Signature

Text

Long answer

‘Thank you’ page

Title

Wallet Connect

We will send you an email with a 6-digit verification code.

Change your email

We've sent a 6-digit verification code to {{email}}. If you don't see it, please check your spam folder and make sure your email address is spelled correctly.

Check your email

Personalize the form links with your own domain. <a href='{{link}}' target='_blank'>Learn about custom domains</a>.

No custom domains yet

Roll up your sleeves and let’s get started. It's as simple as one-two-three.

No forms yet

Important Notice

Rename this form

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Please note that you can only be a member of one organization at a time. Accepting this invitation will transition you to the new organization, and you will no longer have access to your current organization's workspaces and forms. However, rest assured that any forms you've created will be seamlessly transferred to the new organization and will remain visible exclusively to you.

Rename this workspace

If you are sure you want to proceed with the deletion of your account, please continue below. Keep in mind this operation is irreversible and will result in a complete deletion of all your account data - all your forms, submissions and workspaces will be deleted.

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Welcome back to the simplest way to create beautiful forms & surveys.

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Collection of templates for you to use in your own forms.

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Oops, the domain was not found!

Add custom styles (e.g. change color, fonts) or scripts (e.g. Google Analytics tracking code, Intercom, Buy Me a Coffee, etc) to your Tally form. <a href='{{link}}' target='_blank'>Learn about adding custom styles and scripts</a>.

Common issues

Add these records to your domain name provider’s DNS settings. You can check the DNS records of your domain with this tool: <a href='{{dnsCheckerLink}}' target='_blank'>DNS Lookup</a>.

DNS records

Customize your favicon and add analytics, chat support, or other scripts with code injection.

General settings

Instructions

Control how your URLs are displayed around the web and when shared on social media.

Meta data

Control how <a href='{{link}}' target='_blank'>{{link}}</a> is displayed around the web and when shared on social media.

Map your published Tally forms to your domain and customize the URLs.

Pretty URLs

Tally automatically issues and renews SSL Certificates for your domain.

SSL certificates

If your domain is not resolving to our servers, please use the <a href='{{letsDebugLink}}' target='_blank'>Let's Debug</a> tool to identify the potential issue. You can check the DNS records of your domain with this tool: <a href='{{dnsCheckerLink}}' target='_blank'>DNS Lookup</a>. If the issue persists, please contact us hello@tally.so.

Troubleshooting

Receive email updates on what we built, why we built it, and how to use it.

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This page doesn't exist. If you think there is something off, please contact us.

Oops, page was not found!

One of the text properties is too long. Text can be maximum 2000 characters long.

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Oops, something is off!

We'll send a 6-digit reset code to your email.

We've sent a 6-digit verification code to {{email}}. If you don't see it, please check your spam folder and make sure your email address is spelled correctly.

Reset password

Send password reset code

Works with links of PDFs, Calendly, Google Maps, Tweets, public Figma files and more

Works with SoundCloud, Spotify, MP3s and more

Works with YouTube, Vimeo, Loom, MP4s and more

Easily insert multiple options at once by typing or pasting list of options separated with new lines.

You are all set to publish the changes to your form.

Size limit: {{size}} {{unit}}. For unlimited file uploads <a href='#'>upgrade to Tally Pro</a>.

Click to choose a file or drag here

Search for any input field or layout option. Use <ArrowUp /> and <ArrowDown /> to browse the list, then hit <Enter /> to insert the selected block.

Insert anything

No content blocks match your search. Retry with a different keyword.

No results

You can insert a question combined with an input field or just a question title.

Insert questions

Questions

Collect and receive payments directly on your bank account powered by Stripe. Free Tally users collect payments at the the rate of 5% Tally commission + Stripe transaction fee.

Collect and receive payments directly on your bank account powered by Stripe.

To remove the 5% Tally commission on payments, <a href='#'>upgrade to Tally Pro</a>.

Form title

Type a question

You are all set to publish your form. Once your form is published, you will be able to access it in your dashboard and can share it with your respondents.

Ready, set, go!

Please ask the form creator to invite you to their workspace.

Oops, you don't have access to this form!

This form doesn't exist. If you think there is something off, please contact us.

Oops, the form was not found!

Your form is published and ready to be shared with the world!

No completed submissions yet

Here are all the integrations connected to this form. You can easily enable or disable an integration and track submission sync requests using the event history log.

Make Tally even more powerful by using these tools. Check out our <a href='{{link}}' target='_blank'>roadmap</a> for upcoming integrations and to request new ones.

This question is untitled because the input field doesn't have a placeholder text, a label or a question title block above it. You can fix it by editing the form.

Schedule a date on which the form will be closed for new submissions.

Close form on a scheduled date

People won't be able to respond to this form anymore.

Close form

This is what the recipients will see if you closed the form with one of the options above.

Closed form message

Choose in what language the respondents will see your form. This applies to the text which is not customized by you e.g. default buttons, errors, etc.

Text direction

Language

Automatically jump to the next page when a question gets answered. Only works with one multiple choice, dropdown, rating or linear scale question per page.

Auto-jump to next page

Collect answers from people who filled in a part of your form, but didn’t click the submit button. You can't export partial submissions with integrations, nor enable email notifications.

Partial submissions

Enable this setting to require a password before respondents can access the form.

Password protect form

Ensure each respondent can only submit the form once by selecting a form field (e.g. email address, phone number, IP address) that will be used as a unique identifier. This allows our system to detect and prevent duplicate submissions.

Prevent duplicate submissions

The progress bar provides a clear way for respondents to understand how much of the form they have completed, and encourages them to continue until the end.

Progress bar

Redirect to a custom URL when the form is submitted.

Redirect on completion

Tally branding

Send a customized text email to respondents after form submission.

Respondent email notifications

Save answers of not-submitted forms, so respondents can continue from where they left off. The answers are stored in the local browser storage and never leave the respondent’s computer.

Save answers for later

Get an email when someone completes this form. You can fully customize the email's recipient(s), subject and message.

Self email notifications

Automatically delete form submissions after a set period. Enable this option to define how long submissions are stored before they’re deleted. When disabled, submissions will be retained until manually deleted.

Submissions data retention

Set how many submissions you want to receive in total.

Limit number of submissions

Use these options to embed your form into your own website.

Automatically hide the popup after the form is submitted. Optionally set a delay in seconds.

Fully customize the look of your forms with CSS code injection via your custom domain.

After the visitor submits the form, don't show the popup again

Automatically adjust the height of the embed to fit the form content.

Hide form title

Show the popup only once to the same visitor

Embed Form

Your form is now published and ready to be shared with the world! Copy this link to share your form on social media, messaging apps or via email.

Share Link

Do you want others to be able to use your form as a template? Create a template and share the link for others to use.

Form template

Create a template

No partial submissions

Collect answers from people who filled in a part of your form, but didn’t click the submit button. Capture data from lost leads, find drop off points and improve your conversion rates. You can't export partial submissions with integrations, nor enable email notifications.

The form can't receive new submissions at this moment.

This form is now closed

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It looks like you have already filled out this form. To prevent duplicate entries, only one submission per respondent is permitted.

Form submission not accepted

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Use tons of free advanced features like collecting payments, conditional form logic, answer piping, calculations, hidden fields and many more.

Collect any type of data

Analyze your form submissions with detailed reports. Export data and automate workflows through Zapier, Make, Google Sheets, Notion, Airtable, Slack, webhooks, and more.

Get more out of your data

Create forms for all purposes in seconds. Without knowing how to code, and for free!

Tally is a new type of form builder that works like a doc. It makes form building easy and offers tons of powerful features for free.

We make form building accessible to everyone. Explore, pick, and customize templates to your needs.

Designed for you

Create as many forms as you like for free. Get unlimited submissions and access to all form fields.

That’s right, free.

It’s easy as one-two-three. Take a peek at <a href='{{link}}' target='_blank' rel='noreferrer'>what our users have to say</a>.

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Share a form link, connect custom domains, and embed your form into your website or Notion page.

Easily share or embed

Organize forms in workspaces, collaborate with your team and manage access rights.

Organize your team

This log keeps track of all submission sync requests that are sent to Airtable

Airtable events log

Airtable uses simple token-based authentication. To generate or manage your API key, visit your <a href='{{link}}' target='_blank'>Airtable account page</a>.

To obtain the ID of your Airtable base, open the <a href='{{link}}' target='_blank'>Airtable API page</a> and click on the base that you want to use. You will find the ID of your base in the Introduction section.

Send submissions to Airtable. <a href='{{link}}' target='_blank'>Learn about Airtable integration</a>.

Map Tally to Airtable fields. It's crucial to type the Airtable field names exactly as they appear in your table e.g. Name, Notes, Status, etc. If you change a field name on Airtable, please update it here too, otherwise the integration won't work as expected.

It's crucial to type the table name exactly as it appears in your Airtable base e.g. Table 1. If you change the table name on Airtable, please update it here too, otherwise the integration won't work as expected.

Connect with Airtable

An optional name describing what the integration is used for

Connection name

This integration hasn't received any events so far.

No events yet

Measure, optimise and build audiences for your advertising campaigns. <a href='{{link}}' target='_blank'>Learn about Meta Pixel integration</a>.

Connect with Meta Pixel

Google Analytics uses cookies for measurement and marketing. If applicable, we recommend showing a cookie banner on this form to comply with GDPR and other privacy regulations (supports Google Consent Mode v2).

View and analyze traffic sources, visitor behaviors, time spent on your form, and more. <a href='{{link}}' target='_blank'>Learn about Google Analytics integration</a>.

Connect with Google Analytics

This log keeps track of all submission sync requests that are sent to Google Sheets

Google Sheets events log

Send your Tally form responses straight to Google Sheets. <a href='{{link}}' target='_blank'>Learn about Google Sheets integration</a>.

Connect with Google Sheets

This log keeps track of all submission sync requests that are sent to Notion

Notion events log

Send submissions to Notion. <a href='{{link}}' target='_blank'>Learn about Notion integration</a>.

Connect your databases with Tally: open a database in Notion, click the '...' button in the top-right corner → Connections → Add connections → Tally.

Connect with Notion

This log keeps track of every message sent to your Slack channels

Slack events log

Send Slack messages for new submissions. <a href='{{link}}' target='_blank'>Learn about Slack integration</a>.

If you don't see a channel or DM, you need to invite Tally's Slack bot to the conversation by typing "/invite @Tally_Forms" in the Slack channel or DM.

Connect with Slack

Export all form submissions to {{integration}}. Note that exporting may take some time for forms with many submissions.

Export existing submissions

This log contains all requests made to your webhook endpoint. <a href='{{link}}' target='_blank'>Learn about webhooks</a>.

This webhook hasn't received any events so far.

Webhook events log

Webhooks allow you to receive HTTP POST requests to a URL for new form submissions. <a href='{{link}}' target='_blank'>Learn about webhooks</a>.

Add a webhook endpoint

Edit webhook endpoint

Create ActiveCampaign contacts from new form submissions

Add new form submissions to Asana as tasks

Export your submissions to an Excel spreadsheet

Send email notifications for new submissions

Analyze traffic sources, visitor behavior and time spent

Create Google Calendar events from new submissions

Create a contact in Hubspot for every new submission

Sync data with Mailchimp and send follow up emails

Generate PDF documents for new form submissions

Create a new Salesforce lead for new submissions

Send SMS messages for new form submissions

Create Trello cards from new form submissions

Send events for new submissions to HTTP endpoints

Submissions are synced with this <a href='{{link}}' target='_blank'>spreadsheet</a>

Add title

Welcome back

Enter an authenticator app code or a recovery code

Two-factor authentication

Tally

Allows {{client}} to get a list of your existing forms

Allows {{client}} to get a list of a form's submissions

Allows {{client}} to access your name, email and avatar

Allows {{client}} to read and manage webhooks

Forms

Submissions

Account details

Webhooks

To continue, please authorize {{client}} to access the following information from your Tally account:

Inject custom CSS to fully customize the design of your forms.

Custom CSS

Host forms on your own (sub)domain to create branded form URLs and get access to code injection.

Custom domains

Send fully customized and dynamic text emails to yourself or respondents after form submission.

Email notifications

Invite team members to collaborate on forms in shared workspaces and share form results.

Collaboration

Remove 5% Tally commission on your incoming payments and only pay the Stripe transaction fee.

No commission

Capture unfinished form responses before respondents submit your form.

Remove all Tally branding and have your forms seamlessly represent your brand.

No Tally branding

Send a fully customized text email to the respondents of your forms.

Remove the 10 MB per file size limit when using the File Upload block.

Unlimited uploads

Group related forms in workspaces and manage team members' access rights.

Workspaces

Billing information

Tally Pro is required

Without Tally Pro, you can only access forms in the workspace "{{workspace}}". To regain access to the forms in other workspaces, you can move all forms to this workspace, or reactivate Tally Pro.

Use this to insert a question with a range of answers. Respondents can select multiple answers.

Use this to insert a question with a long list of answer options.

Use this to insert a question and collect files.

Use this to insert a question that asks respondents to pick a date in this format: Month Day, Year.

Use this to insert a question and collect correctly formatted email addresses as answers. If someone tries to add text in the wrong format, they will have to try again.

Use this to insert a question to collect correctly formatted links or websites.

Use this to insert a question with a number as response. Use settings to add a minimum and/or maximum number limit.

Use this to insert a question and collect correctly formatted phone numbers.

Use this to insert a question combined with a short text answer. Add an answer label or placeholder text for guidance.

Use this to insert a question that allow respondents to pick a time in this format: XX:XX

Use this to insert a question and receive for numeric answers on a scale. Go to settings to adjust the scale size and add a scale label on the left, center and/or right.

Use this to add a question with a range of answer options. Respondents can only choose one answer.

Use this to insert a question and accept payments securely via Stripe (fees may apply). <a href='{{link}}' target='_blank'>Learn more</a>.

Use this for a simple and visual way of rating things.

Use this to insert a question with a long form answer without character limits.

Use this to insert a question title. You can separately add an input field of your choice.

Untitled checkboxes field

Untitled dropdown field

Untitled file upload field

Untitled date field

Untitled email field

Untitled link field

Untitled number field

Untitled phone number field

Untitled short answer field

Untitled time field

Untitled linear scale field

Untitled matrix field

Untitled multiple choice field

Untitled multi select field

Untitled payment

Untitled ranking field

Untitled rating field

Untitled signature

Untitled long answer field

Untitled Wallet Connect field

Please enter your password to regenerate your backup codes.

Regenerate backup codes

This will permanently delete your entire account. All your forms, submissions and workspaces will be deleted.

Connect your Tally account with Google or Apple to enable faster, secure and more convenient access.

Connected accounts

Secure your account with two-factor authentication which adds an additional layer of security during login.

If you get locked out of your account, you can restore access with any of the following one-time use codes. It is important to save these now and keep them in a safe space.

Review and save your two-factor authentication recovery codes

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Subscription changes are handled by your organization owner. Contact {{name}} at {{email}}.

Add your name and create a password to finish setting up your Tally account.

Tell us a little about yourself

Welcome, {{name}}

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Payment received

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Open the formatting menu by selecting text

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Here you will find forms, submissions and workspaces which you deleted in the last 90 days and you can easily restore them.

Medical History Form

Personal details:

Gender

First name

Surname

Date of birth

Contact details

Phone number

Mobile number

E-mail

Address details

Adress

City

Postcode

Country

Different billing address?