Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Medical History Questionnaire
Medical History Form Please fill out the following form to provide your medical history.
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? *
- Diabetes
- Hypertension
- Asthma
- Heart Disease
- Cancer
- Chronic Pain
- Arthritis
- High Cholesterol
- Other
Have you had any surgeries?
Are you currently under any medical treatment?
Do you use any assistive devices (e.g., glasses, hearing aids)?
- Glasses
- Contact Lenses
- Hearing Aids
- Cane/Walker
- Wheelchair
- None
Do you smoke?
Do you consume alcohol?
Family History of Medical Conditions
Additional Information or Concerns
Signature
Date
Medical History Questionnaire template from formisoft.com. formisoft.com/intake-templates/medical-history