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Patient Health Questionnaire Form Template

Streamline Patient Assessments with This Effective Template

Collecting accurate health information can be challenging for healthcare providers, but with this Patient Health Questionnaire Template, you can simplify the process. Designed for medical professionals, this template enables you to efficiently gather essential details about your patients' medical history, lifestyle habits, presenting complaints, and family medical history. By using this straightforward form, you can enhance patient engagement, ensure thorough evaluations, and foster better communication within your practice. Experience the convenience of a WCAG-aligned, user-friendly template-try it out now.

Use this Template (FREE) Live Preview
Full name
Date of birth
Preferred language
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email
Mobile phone
Street address
City
State/Province
Postal code
Emergency contact full name
Emergency contact relationship
Emergency contact phone
May we leave a voicemail at this number?
Yes
No
Insurance provider (optional)
Member ID / Policy number (optional)
Primary care physician or clinic (optional)
Do you have health insurance?
Yes
No
What brings you in today?
When did these symptoms start?
Less than 24 hours
1-3 days
4-7 days
1-4 weeks
More than 1 month
Not applicable
How severe is your discomfort today?
None
Mild
Moderate
Severe
Very severe
Have you ever been diagnosed with any of the following conditions?
Please Specify:
Past surgeries or hospitalizations?
Yes
No
Please list surgeries or hospitalizations with year (optional)
Are you currently taking any medications or supplements?
Yes
No
Please list current medications and doses (optional)
Do you have any allergies to medications, foods, or substances?
Yes
No
Not sure
Please list allergies and reactions (optional)
Family history of significant conditions (select all that apply)
Please Specify:
Tobacco use
Never
Former
Some days
Every day
Prefer not to say
Alcohol use frequency
Never
Rarely
Sometimes
Often
Always
Recreational drug use
Never
Former
Occasionally
Frequently
Prefer not to say
Physical activity frequency
Never
Rarely
Sometimes
Often
Always
Are you currently pregnant or breastfeeding?
Yes
No
Not applicable
Prefer not to say
Please describe any accessibility needs (optional)
Do you have any accessibility needs or accommodations?
Yes
No
Preferred appointment reminder method
Email
SMS/Text
Phone call
No reminders
Do you consent to receive reminders and updates via electronic communications?
Yes
No
I consent to evaluation and treatment as determined appropriate by the healthcare provider.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Type your full legal name as your signature
Date signed
I acknowledge receipt of privacy practices information (HIPAA).
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration depicting a Patient Health Questionnaire form for FormCreatorAI article.

When to use this form

Use this form before appointments, at check-in, or for telehealth to capture symptoms, history, medications, allergies, and lifestyle in one place. It helps primary care, specialists, behavioral health, and urgent care teams get a clear picture fast. Send it to new patients so you can focus the first visit; pair it with the New patient registration form to collect demographics and insurance. During the visit, use the Patient encounter form to track vitals, notes, and follow-ups without repeating questions. For annual physicals or sports clearances, add the Health examination form to document screenings and risk factors. The result: safer decisions, shorter visits, and better continuity across your care team.

Must Ask Patient Health Questionnaire Questions

  1. What is your main concern today, and when did it start?

    This focuses the visit and sets priority. Onset and duration help triage urgency and guide testing or referrals.

  2. Which diagnoses do you have, and what medications and allergies should we know about?

    Listing conditions, meds, and allergies prevents unsafe prescribing and interactions. For deeper history, pair with the Health examination form to capture details your clinician will rely on.

  3. Have you experienced changes in mood, anxiety, or sleep in the past two weeks?

    A brief mental health check can reveal issues that affect treatment and recovery. Time-bound wording improves recall and supports consistent follow-up.

  4. Have you had surgeries, hospital stays, or major test results we should consider?

    Past events often explain current symptoms and risks. Knowing them avoids duplicate tests and speeds decisions during your visit.

  5. What lifestyle habits or supplements (tobacco, alcohol, activity, diet, substances) may affect your care?

    Lifestyle drives many conditions and can change medication choices. If you use herbal remedies or alternative therapies, the Alternative medicine-patient intake form helps document them for safe planning.

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