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Medical Questionnaire Form Template

Streamline Health Assessments with Our Medical Questionnaire Template

Are you struggling to assess patients' fitness for activities? Our Medical Questionnaire Form Template supports healthcare professionals by simplifying how you gather essential health information. With this customizable template, you can efficiently screen for medical conditions, ensure compliance with safety protocols, and enhance patient care, all while providing a user-friendly experience. Plus, the form is designed with WCAG-aligned labels to promote accessibility. Explore how you can effortlessly create your questionnaire today.

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Full legal name
Date of birth
Email address
Mobile phone number
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Emergency contact full name
Emergency contact phone
Relationship to you
Primary care provider or clinic name
Insurance provider
Policy or member number
What is the main reason for your visit today?
Which symptoms are you experiencing right now? Select all that apply.
Please Specify:
How long have these symptoms been present?
Under 24 hours
1-3 days
4-7 days
1-4 weeks
Over 1 month
Intermittent or unsure
How would you rate your current pain level?
None
Mild
Moderate
Severe
Worst imaginable
List any medication allergies or reactions (write None if none)
List all current medications and doses (write None if none)
Have you been diagnosed with any of the following conditions? Select all that apply.
Please Specify:
List any past surgeries or hospitalizations with approximate dates (write None if none)
Are your routine immunizations up to date?
Yes
No
Unsure
Is there a possibility that you are currently pregnant?
Yes
No
Not applicable
Prefer not to say
Do any blood relatives have the following conditions? Select all that apply.
Tobacco use
Never
Former
Current
Prefer not to say
Alcohol use frequency
Never
Rarely
Sometimes
Often
Always
Prefer not to say
Exercise frequency
Never
Rarely
Sometimes
Often
Always
I consent to the collection and use of my health information for care and healthcare operations.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Signature (type your full name)
Signature date
I certify that the information I have provided is true and complete to the best of my knowledge.
True
False
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth, Email address","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a medical questionnaire form for FormCreatorAI article.

When to use this form

Use this form before office visits, clearances, and hiring screens. Clinics use it to capture symptoms, history, medications, and allergies so providers act fast and safely. It is helpful for routine checkups paired with the Adult physical exam form. Specialists and primary care teams use it ahead of procedures or referrals to speed reviews for the Medical clearance form. Employers can collect job-related health details and respirator risks alongside the Employee physical examination questionnaire form. It also fits telehealth intakes and annual updates, reducing back-and-forth and missed risks. The outcome: complete, structured answers you can route to the right clinician, trigger follow-up questions, and document consent and safety flags.

Must Ask Medical Questionnaire Questions

  1. What are your current symptoms, and when did they start?

    Onset and pattern help triage urgency and narrow likely causes. Clear timelines guide which tests, isolation steps, or urgent care actions you take.

  2. Do you have any chronic conditions (for example, asthma, diabetes, heart disease), and who manages them?

    Ongoing illnesses change risk, treatment choices, and follow-up plans. Listing the treating clinician speeds coordination and medication verification.

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

    Accurate lists prevent interactions and adverse reactions during exams or procedures. If respirator use is required, this also supports screening tied to the N95 Fit-test form.

  4. Have you had any surgeries, hospital stays, or major injuries in the past 5 years?

    Prior procedures signal anesthesia and bleeding risks and guide imaging or labs. For upcoming operations, responses streamline review for the Surgery clearance form.

  5. What is your work environment and lifestyle (smoking, alcohol, exercise), and any job-specific exposures?

    These factors affect screening needs, vaccines, and restrictions. The details help tailor counseling and safe duty assignments.

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