Health History Questionnaire

A health history questionnaire is a means by which a physician can have an elementary idea about the patient’s health before he starts his treatment. Mostly hospitals and private medical practitioners used this questionnaire. Such questionnaires help the doctors to provide better treatment to their patients.

Sample Health History Questionnaire

Date: –/–/—- [dd / mm / yyyy]

Name of the patient: __________________________________________

Address: ____________________________________________________

Contact No.: _____________________

Sex: Male / Female

Date of birth: –/–/—- [dd / mm / yyyy]

1. Please mention your marital status.

a. Single

b. Partnered

c. Married

d. Separated

e. Divorced

f. Widowed

2. Please mention the name of your previous consulting doctor.


3. What was the date of your last medical check up? –/–/—- [ dd / mm / yyyy ]

4. Please give details of that check up.


5. Have you ever suffered from any childhood illness?

a. Yes

b. No.

If Yes, Please provide details ____________________________________

6. Have you taken the following immunization dosages?

a. Tetanus- Yes / No

b. Pneumonia- Yes / No

c. Hepatitis- Yes / No

d. Chicken Pox- Yes / No

e. Influenza- Yes / No

f. MMR- Yes / No

7. Have you ever transfused blood?

a. Yes

b. No

If yes, mention when and where? _______________________________________

8. How often do you suffer from cough, cold and fever?

a. Very rarely

b. Sometimes

c. Very frequently

9. Do you feel lethargic in carrying out your daily activities?

a. Never

b. Sometimes

c. Always

Category: Health Questionnaire

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