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Health Questionnaire Form Template

Effortlessly gather vital health information with our user-friendly template.

Collecting health information can be daunting, but this Health Questionnaire Form Template simplifies the process for you. Designed to help healthcare professionals and clinics gather essential data from patients, this template enables you to capture detailed medical histories and monitor health changes effectively. Benefit from streamlined data collection, enhanced patient communication, and improved record-keeping, all while ensuring compliance with health standards. Start using the live template today to make your patient intake smoother.

Use this Template (FREE) Live Preview
Full name
Date of birth
Email address
Phone number
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Emergency contact full name
Emergency contact phone
Relationship to you
Have you ever been diagnosed with any of the following conditions?
Please Specify:
If you selected Other or would like to add details, please describe
List any past surgeries or hospitalizations with dates (if none, write N/A)
Allergies
No known allergies
Medications
Food
Environmental (e.g., pollen)
Insect stings
Latex
Other
Please Specify:
Please list specific allergies and reactions
Do you currently take any prescription or over-the-counter medications or supplements?
Yes
No
List current medications and supplements with dose and frequency (if none, write N/A)
Family medical history (immediate family)
Height
Weight
Tobacco or vaping use
Never
Former
Current daily
Current occasional
Vaping only
Prefer not to say
Alcohol use frequency
Never
Rarely
Sometimes
Often
Always
Physical activity frequency
Never
Rarely
Sometimes
Often
Always
Dietary preferences or restrictions
Please Specify:
What is the main reason for your visit or consultation today?
Are you currently experiencing any of the following symptoms?
Please Specify:
Are you experiencing pain today?
Yes
No
Immunization status
Up to date
Some missing or overdue
Not sure
Prefer not to say
Are you currently pregnant or planning a pregnancy?
Currently pregnant
Planning pregnancy
Not pregnant
Not applicable
Prefer not to say
When did you last have a general health checkup?
Within the past year
1-2 years ago
2-5 years ago
More than 5 years ago
Never
Not sure
Preferred contact method
Email
Phone call
Text message
No preference
I authorize the healthcare provider to obtain and/or release my medical information as needed to coordinate my care
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Type your full legal name to sign
Signature date
I confirm the information provided is accurate to the best of my knowledge
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration depicting a health questionnaire form with checkboxes and questions for FormCreatorAI article

When to use this form

Use this questionnaire before first visits, pre-op checks, telehealth triage, school sports clearances, and workplace wellness screens. It gives clinicians a quick, structured view of symptoms, risks, meds, and history. Front desk teams often send it with the Patient intake form to cut waiting room paperwork. For complex symptom stories, pair it with the HPI Form to capture onset, triggers, and severity. Specialty clinics, like chiropractic or sports medicine, can tailor questions toward pain and function; the Chiropractic intake form shows discipline-specific fields. The result is faster charting, safer decisions, and fewer follow-up calls. Patients avoid repeating details, and your team gets cleaner data for the EMR or telehealth notes.

Must Ask Health Questionnaire Questions

  1. What symptoms are you experiencing today, when did they start, and are they getting better or worse?

    Time course and trend reveal urgency and likely causes. Clear symptom details guide triage, testing, and next steps.

  2. Do you have any chronic conditions, past surgeries, or recent hospitalizations?

    History shapes risk, medication choices, and follow-up plans. It also prevents duplicate work and flags complications to watch.

  3. What medications and supplements do you take, and do you have any drug or food allergies?

    This reduces adverse reactions and harmful interactions. It helps clinicians reconcile the med list and choose safe treatments.

  4. What is your typical lifestyle: tobacco or vaping, alcohol, exercise, sleep, and diet?

    Habits often drive symptoms and recovery. These answers unlock practical coaching and tailored care plans.

  5. What are your goals for this visit and any concerns about treatment?

    Stating goals aligns the care plan with what matters to you and improves engagement. You can later assess perceived outcomes with a brief Patient satisfaction questionnaire form.

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