Free Medical History Questionnaire

Collect detailed health information with the Medical History Questionnaire Template from Template.net. This customizable and editable template is designed for healthcare providers to document patient medical histories, symptoms, and past treatments. Use the Ai Editor Tool to adjust questions to meet specific medical requirements, ensuring comprehensive patient information and accurate records for better healthcare outcomes.

Free Medical History Questionnaire

Personal Information

Name

Date of Birth

Address

Phone number

Email

Emergency Contact

Name

Relationship

Phone number

Medical History

Do you have any existing medical conditions?

If yes, please specify:

Are you currently taking any medications?

If yes, please list:

Do you have any allergies?

If yes, please specify:

Have you had any surgeries in the past?

If yes, please provide details:

Do you have a family history of any major illnesses?

If yes, please specify:

Lifestyle Information

Do you smoke?

If yes, how many per day?

Do you consume alcohol?

If yes, how often?

Do you exercise regularly?

If yes, how often?

Additional Information

Signature

Thank you for submission!

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