Patient Health History Questionnaire Template

As part of our effort to provide you with the best possible care, we would like to invite you to complete this questionnaire in order to better understand your medical history and any current health concerns you may have. Your responses will be kept confidential and will only be used to provide you with the most appropriate care. Thank you for taking the time to share your health information with us.
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1. Personal Information

Name
Name
Date of Birth
Date of Birth
Gender
Gender

2. Medical History

*a. Have you ever been diagnosed with any of the following conditions? (check all that apply)[Checkboxes]
High blood pressure
Diabetes
Heart disease
Lung disease
Kidney disease
Liver disease
Stroke
Cancer
Depression or anxiety
Other (please specify)
*b. Have you ever had surgery? If so, please provide details:
Yes
No
*c. Do you have any allergies? If so, please list them:
Yes
No
*d. Are you currently taking any medications? If so, please list them:
Yes
No
*e. Have you ever had any adverse reactions to medications? If so, please provide details:
Yes
No

3. Lifestyle and Habits

*a. Do you smoke? If so, how many cigarettes per day?
Yes
No
*b. Do you drink alcohol? If so, how many drinks per week?
Yes
No
*c. How often do you do exercise?
5 or more times a week
3-4 times a week
1-2 times a week
Less than once a week
Never
*d. Do you follow a healthy diet? If so, please describe:
Yes
No
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