Medical History Questionnaire
Form Preview
Medical History Questionnaire
Page 1 of 3
Sign up and start customizing in minutes.
The Medical History Questionnaire is a comprehensive health background document that captures a patient's complete medical story. It covers past and present medical conditions organized by body system, current medications with dosages and frequencies, allergy documentation with reaction types, surgical history with dates and outcomes, and family medical history for hereditary condition screening.
This form is essential for new patient onboarding across all specialties. It provides the clinical foundation that providers need to make informed treatment decisions, identify potential drug interactions, and screen for hereditary disease risk. The review of systems approach ensures no major health area is overlooked.
The questionnaire uses a smart checklist format that makes it easy for patients to complete without medical knowledge. Common conditions are listed by category (cardiovascular, respiratory, gastrointestinal, neurological, etc.) with the ability to add free-text details. Social history covers tobacco, alcohol, recreational drug use, exercise habits, and occupation. This template can be used standalone or combined with any specialty intake form.
What's included
- Past medical conditions by body system
- Complete surgical history with dates
- Medication list with dosages and frequency
- Allergy documentation (drug, food, environmental)
- Family medical history for hereditary screening
- Social history (tobacco, alcohol, exercise)
- Medical conditions checklist
Who uses this template
- Any medical practice onboarding new patients
- Annual health record updates
- Pre-operative medical clearance
- Specialist referral documentation
All form fields
10 fields across 3 pages. 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 free Formisoft trial, then select the Medical History Questionnaire from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
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 10 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
Is the Medical History Questionnaire HIPAA compliant?
Yes. All Formisoft templates, including the Medical History Questionnaire, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 10 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?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
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
Structured family history form covering hereditary conditions across first and second-degree relatives. Organized by condition category for genetic risk screening and preventive care planning.
Adoption Medical History Form
Specialized medical history form for adopted children and adults documenting available birth family health information, prenatal history, and early childhood medical records. Essential for adoption agencies, pediatricians, and family medicine practices.
Aviation Medical Examination History
Comprehensive medical history form for FAA aviation medical examinations covering neurological conditions, cardiovascular health, psychiatric history, and medication use. Required for pilots seeking first, second, or third class medical certificates for flight operations.