Health History Questionnaire

The Health History Questionnaire is a tool used by healthcare professionals to collect information about a patient’s health.

2 minutes to complete


Any person who has been advised by a doctor, physician, healthcare professional, or any other relevant healthcare provider can fill the Health History Questionnaire.


Questions for Health History Questionnaire



What is your name?

The answer should be a text input.


The answer should be a date input.

Please complete the following questions to the best of your ability. If you have any questions, please ask your provider or staff member. The information you provide will be kept confidential.


Please list any medical conditions for which you have been treated:

The answer should be a text input.

Please list any medications that you are currently taking (including over-the-counter medications, vitamins, and/or herbs):

The answer should be a text input.

Have you ever had any of the following? Select all that apply.

The answer should be a multiple choice:
  1. Allergies (to food, medication, environmental, etc.)
  2. Asthma
  3. High blood pressure
  4. High cholesterol
  5. Diabetes
  6. Heart disease or heart attack
  7. Cancer
  8. Thyroid problems
  9. Kidney problems
  10. Liver problems
  11. Autoimmune disease
  12. Ulcers
  13. Seizures

Questionnaires Similar to Health History Questionnaire

  • Patient Health History Questionnaire
  • New Patient Health History Questionnaire
  • Health History
  • Screening Questionnaire
  • Patient Health and Medical History Questionnaire
  • Personal Health History Questionnaire
  • Family Health History Questionnaire
  • Medical History Questionnaire
  • Dental Health History Questionnaire
  • Previous Medical/Health History Questionnaire

Here are some FAQs and additional information
Health History Questionnaire

How often should I complete the Health History Questionnaire?

Usually, the Health History Questionnaire should be completed at least once per year.

What is the purpose of the Health History Questionnaire?

The purpose of the Health History Questionnaire is to provide your healthcare provider with important information about your health. This information can help your healthcare provider make informed decisions about your care.

What information should I include in the Health History Questionnaire?

You should include information about your medical history, family history, current medications, allergies, and any other health concerns you may have.

Want to use this template?

Loved by people at home
and at work

“BlockSurvey is a simple, effective, and scalable tool for creating surveys for leadership and learning assessment. It's one of this year's best buying choices. Each month, it keeps improving and strives to serve its customers needs.”
Nelson Emilio
Personal Branding Strategist
“I use BlockSurvey to get feedback about all my activities and events. It is really easy to get started and create my first surveys! Then I could see how easy it was to share them. Now I am thinking to use BlockSurvey also within my creative process as an author in order to listen and engage with my audience, knowing that anonymity provides the most sincere and reliable answers.”
Georgina García-Mauriño
Author & Designer
BlockSurvey social proof
G2 Crowd
4.8 Star Rating
BlockSurvey social proof
Editor's choice
BlockSurvey social proof
4.9 Star Rating

What's next? Try out templates like
Health History Questionnaire

1000+ Templates, 50+ Categories

Want to create secure online forms and surveys?

Join BlockSurvey.