Medical History Questionnaire
Detailed health history covering conditions, surgeries, family history, and lifestyle.
Free · No credit card required · 12 fields · Customize everything
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What's Included
12
Fields
1
Steps
2
Categories
1
Industries
Form Fields
This template includes 12 fields. Here's what respondents will see:
| Field | Type | Required |
|---|---|---|
| Patient Full Name | short answer | Yes |
| Date of Birth | date | Yes |
| Chronic Conditions (check all that apply) | checkbox | No |
| Past Surgeries | long answer | No |
| Past Hospitalizations | long answer | No |
| Family Medical History | long answer | No |
| Current Medications & Supplements | long answer | No |
| Allergies (medications, foods, environmental) | long answer | No |
| Smoking Status | radio | Yes |
| Alcohol Consumption | dropdown | Yes |
| Exercise Frequency | dropdown | Yes |
| Blood Type (if known) | dropdown | No |
Frequently Asked Questions
How is this different from a patient intake form?
The medical history questionnaire focuses on clinical history — conditions, surgeries, family history, lifestyle. A patient intake form also captures demographics, insurance, and consent. The two are often used together.
Is this form HIPAA compliant?
The template collects minimum-necessary PHI. HIPAA compliance also depends on how you store and transmit submissions — use encrypted email or a HIPAA-secure form backend.
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