Medical history questionnaire
Conditions, surgeries, family history, and lifestyle habits in one questionnaire.
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Personal history
Medical history
First Name
Last Name
| Yes | No | |
|---|---|---|
| Diabetes | ||
| High blood pressure | ||
| Asthma or lung disease | ||
| Heart disease | ||
| Thyroid disease | ||
| Cancer | ||
| Depression or anxiety |
Family & lifestyle
| Never | Occasionally | Several times a week | Daily | |
|---|---|---|---|---|
| Smoke or vape | ||||
| Drink alcohol | ||||
| Exercise 30+ minutes |