Medical History Questionnaire

This form is used to collect a patient's medical history, current medications, allergies, and relevant health information to assist healthcare providers in delivering optimal care.

Patient Information

Full Name: {fullName}

Date of Birth: {dateOfBirth}

Gender: {gender}

Phone Number: {phone}

Email Address: {email}

Emergency Contact Name: {emergencyContactName}

Emergency Contact Phone: {emergencyContactPhone}

Primary Care Provider

Provider Name: {providerName}

Clinic Name: {clinicName}

Phone Number: {providerPhone}

Medical History

Check any conditions that apply to you:

{#medicalConditions}

• {condition}

{/medicalConditions}

Other Medical Conditions (not listed above):

{otherConditions}

Surgeries and Hospitalizations

Please list any major surgeries or hospitalizations you have had:

{#surgeries}

• {procedureName} - {year} ({reason})

{/surgeries}

Medications

Provide a list of all current prescription and non-prescription medications:

Allergies

Please list any allergies, including medications, food, or environmental:

{#allergies}

• {allergen}: {reaction}

{/allergies}

{^allergies}

No known allergies.

{/allergies}

Family Medical History

Indicate if any immediate family members have had the following conditions:

Lifestyle & Habits

Do you smoke? {smokeStatus}

Do you consume alcohol? {alcoholStatus}

Do you use recreational drugs? {drugUse}

Exercise frequency: {exerciseFrequency}

Any dietary restrictions? {dietaryRestrictions}

Additional Information

Any additional notes or concerns?

{additionalNotes}