Medical History Questionnaire
Form Preview
Medical History Questionnaire
Page 1 of 1
Sign up and start customizing in minutes.
Start with the Medical History Questionnaire template and tailor it to your practice. It includes 14 editable fields across 1 page. Included questions: Full Name, Date of Birth, Primary Care Physician, Do you have any known allergies?. The full field list below shows what you will get when you add this template to your account.
Choose this template to open an editable form. Review the questions, keep only the information your practice needs, and add your branding. Preview the patient experience before sharing a link or embedding the form. Responses can be reviewed in Formisoft and exported as a PDF.
What's included
- Full Name
- Date of Birth
- Primary Care Physician
- Do you have any known allergies?
- List of Current Medications
- Do you have a history of the following conditions?
- Have you had any surgeries?
- Are you currently under any medical treatment?
- Do you use any assistive devices (e.g., glasses, hearing aids)?
- Do you smoke?
- Do you consume alcohol?
- Family History of Medical Conditions
- Additional Information or Concerns
- Signature
Who uses this template
- Any medical practice onboarding new patients
- Annual health record updates
- Pre-operative medical clearance
- Specialist referral documentation
All form fields
14 fields across 1 page. Customize any field after signing up.
How to use the Medical History Questionnaire
Getting started with this template takes just a few minutes. Sign up for a Formisoft trial, then select the Medical History Questionnaire from the template library. Review the included questions, customize your fields, and preview the form before sharing it.
Setup steps
- 1Choose the template. Find the Medical History Questionnaire in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 14 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
How does Formisoft protect responses?
Formisoft provides secure form collection and a Business Associate Agreement (BAA). Your practice must review the form content, access permissions, and sharing workflow for its requirements.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 14 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
With a plan that includes automation, you can configure workflows to send forms and reminders. Appointment-based sending requires the booking event to reach Formisoft.
Does this template work on mobile devices?
Yes. The Medical History Questionnaire is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Medical History Questionnaire for your practice. Set up in minutes.
Related templates
Family Medical History Form
Customize the Family Medical History template for your practice. 10 editable fields, including Full Name, Cancer History (by Type), Cardiovascular Disease History, Diabetes History.
Medical Marijuana Patient History Form
Customize the Medical Marijuana Patient History template for your practice. 10 editable fields, including Patient Name, Date of Birth, Contact Phone, Qualifying Medical Conditions.
Allergy History Form
Customize the Allergy History template for your practice. 10 editable fields, including Full Name, Drug Allergies, Food Allergies, Environmental Allergies.
