Medical History Questionnaire

Learn about a patient's background before their appointment. It asks about personal and family conditions, current symptoms, medications, allergies, and use of tobacco, alcohol or drugs.

Use this template

Already have an account? Log in

In the Claude connectors directory

Full Name

First Name

Last Name

Age

Gender

Contact Number

Email Address

Conditions that apply to you or your immediate family

Diabetes High blood pressure Heart disease Asthma Cancer Stroke Thyroid disorder None of the above

Symptoms you are currently experiencing

Fever Cough Fatigue Headache Shortness of breath Chest pain Dizziness None

Are you currently taking any medication?

Yes No

Please list your medications

Do you have any medication allergies?

Yes No

Please list your allergies

Tobacco use

Type of tobacco products and length of use

Illegal drug use

Type of drugs and length of use

How often do you drink alcohol?

Never Once a month or less Once a week Several times a week Daily

Related templates

Emotional Support Services Consent Form Healthcare Employee Favorites Questionnaire Human Resources Employee Injury Questionnaire Human Resources Employee Physical Examination Questionnaire Healthcare

Browse all questionnaires templates →

Powerful online forms — builder, logic, products, and teams — at a price that makes sense.

✓ In the Claude connectors directory

Product

Features
Pricing
Compare
Alternatives
Templates
Claude
MCP tools
API
GitHub

Company

Press room
Brand kit
Contact

Legal

Security
Service status
Terms of service
Privacy policy
Cookie policy

Rejoining the server...

Rejoin failed... trying again in seconds.

Failed to rejoin.
Please retry or reload the page.

The session has been paused by the server.

Failed to resume the session.
Please retry or reload the page.