Health History Questionnaire

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

Time to complete

2 minutes

Eligibility

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

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Questions for Health History Questionnaire

1.

What is your name?

The answer should be a text input.
2.

Date

The answer should be a date input.
3.

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.

4.

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

The answer should be a text input.
5.

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.
6.

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

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Here are some FAQs and additional information
on
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.

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