General Medical History Form
A medical history form is a questionnaire that asks a patient to fill out information on their family's medical ailments, previous illnesses or procedures, and other issues that may affect treatment. This type of medical form is necessary in a variety of fields, including academia and research, as well as healthcare.
3 minutes to complete
Eligibility
There is no specific eligibility criteria for filling out a General Medical History Form.
Questions for General Medical History Form
Questions
1.
Name
The answer should be a text input.
2.
Age
The answer should be a single choice:
- Under 18
- 18-24 years old
- 25-34 years old
- 35-44 years old
- 45-54 years old
- Over 55
3.
Contact number
The answer should be a phone number.
4.
Contact Email
The answer should be an email input.
5.
Address
The answer should be a text input.
6.
State / Province
The answer should be a text input.
7.
Country
The answer should be a country.
8.
Do you have any allergies
The answer should be a single choice:
- Yes
- No
9.
Mention the allergy
The answer should be a text input.
10.
Do you follow any specific medication
The answer should be a single choice:
- Yes
- No
11.
Mention the medication type
The answer should be a text input.
12.
Name of the dose
The answer should be a text input.
13.
Times per day
The answer should be a number input.
14.
Mention the vaccines you had in past 6 Months
The answer should be a text input.
15.
Select the medical complication you have or you had in past 6 months
The answer should be a single (or) multiple choice by row and column:
Asthma
Cancer
Diabetes
Emphysema (COPD)
Heart Disease
High Blood Pressure (hypertension)
High Cholesterol
Hypothyroidism/Thyroid Disease
Renal (kidney) Disease
Migraine Headaches
Depression/Anxiety/Bipolar/Suicidal
* Check all that apply
16.
Any significant family history is known
The answer should be a single choice:
- Yes
- No
17.
Relation to patient
The answer should be a multiple choice:
- Father
- Mother
- Spouse
- Child
- Sibling
- Other
18.
Mention the last specific visit
The answer should be a multiple choice:
- Cardiology
- Gastroenterologist (GI)
- OB/GYN
- Neurology
- Pulmonary
- Other
Forms Similar to General Medical History Form
- Family Medical History Form
- Personal Medical History Form
- Immunization History Form
- Prescription History Form
- Allergy History Form
- Surgery History Form
Here are some FAQs and additional information
on General Medical History Form
What are the four types of health history?
There are four elements of the patient history: chief complaint, history of present illness (HPI), review of systems (ROS), and past, family, and/or social history (PFSH).
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