Medical History Questionnaire


A medical history questionnaire is an evaluation tool that is used by physicians to gather information about a patient so as to be able to make a diagnosis and subsequent medical care. Medical history questionnaires are a common feature in the course of seeking medical care. The symptoms that are outlined are recorded and a physical check up is carried out to establish the underlying cause of the condition. It is important for a patient to fill in a medical history questionnaire as the first step. The information that is commonly sought includes age, weight, height, health concerns, family diseases and allergies.

Sample Medical History Questionnaire

Name…………………………………………

Date of birth…………………………………

Sex……………………………………………………

Address…………………………………………City………………………….Zip……………………

Emergency contact……………………………………………………………………………..

Do you have any allergic reaction to certain types of medication?  ……………………………………………

If yes, please specify…………………………………………

Are you currently taking any medication?  …………………………………………….

Have you experienced any seizures?  …………………………………………………………

Have you been tested for anemia?  ……………………………………………………………

If yes, what was the test result?  …………………………………………………………………………

Do you have hypertension or have you had it in the past?  …………………………………………….

Please indicate with a tick whether you have had any of these diseases.

a.Disease of the lungs

b.Disease of the heart

c. Disease of the kidneys

d.Disease of the liver

Have you ever had any chest-related ailment?  ………………………………………………………………………..

Have you felt faint, drowsy or weak in the recent past?  ……………………………………………………………

Have you ever suffered from an injury to the head?  ……………………………………………………………………..

Have you ever been admitted to a hospital?  …………………………………………………………………………………

If yes, please give a brief description of what led to the admission…………………………………………………

Have you had surgery before?  ……………………………………………………………………………………………………….

Do you have any problem with your eyesight?  ………………………………………………………………………………….

The form has been duly completed and patient is liable for any adverse consequence attributed to the failure to release the required information.

Date……………………………………………….. Signature……………………………………….

Category: Medical Questionnaire

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