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.

Questions for General Medical History Form

1.

Name

The answer should be a text input.
2.

Age

The answer should be a single choice:
  1. Under 18
  2. 18-24 years old
  3. 25-34 years old
  4. 35-44 years old
  5. 45-54 years old
  6. Over 55
3.

Contact number

The answer should be a phone number.
4.

Contact Email

The answer should be a 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:
  1. Yes
  2. 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:
  1. Yes
  2. 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:
  1. Yes
  2. No
17.

Relation to patient 

The answer should be a multiple choice:
  1. Father
  2. Mother
  3. Spouse
  4. Child
  5. Sibling
  6. Other
18.

Mention the last specific visit 

The answer should be a multiple choice:
  1. Cardiology
  2. Gastroenterologist (GI)
  3. OB/GYN
  4. Neurology
  5. Pulmonary
  6. Other

General Medical History Form FAQ

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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