Patient health history questionnaire template questions in this example
1. Please complete the following:
The answer should be a multi line text input.
2. Have you had any major surgeries or hospitalisations in the past?
The answer should be a single choice:
- Yes
- No
- I'm not sure
- Prefer not to answer
3. Do you have any chronic medical conditions such as diabetes, hypertension, asthma, or heart disease?
The answer should be a single choice:
- Yes
- No
- I'm not sure
- Prefer not to answer
4. Have you ever been diagnosed with any mental health conditions such as depression or anxiety?
The answer should be a single choice:
- Yes
- No
- I'm not sure
- Prefer not to answer
5. Have you ever been diagnosed with any infectious diseases such as tuberculosis or hepatitis?
The answer should be a single choice:
- Yes
- No
- I'm not sure
- Prefer not to answer
6. Do you have any allergies to medications or food?
The answer should be a single choice:
- Yes
- No
- I'm not sure
- Prefer not to answer
7. Do you smoke or use tobacco products?
The answer should be a single choice:
- Yes, daily
- Yes, occasionally
- No, never
- I used to, but I quit
8. Do you consume alcohol?
The answer should be a single choice:
- Yes, daily
- Yes, occasionally
- No, never
- I used to, but I quit
9. Do you exercise regularly?
The answer should be a single choice:
- Yes, daily
- Yes, 3-5 times per week
- Yes, 1-2 times per week
- No, never
10. Has anyone in your immediate family been diagnosed with any chronic medical conditions or mental health conditions?
The answer should be a single choice:
- Yes
- No
- I'm not sure
- Prefer not to answer
11. List all current medications you are taking including prescription drugs, over-the-counter medications, and supplements:
The answer should be a multi line text input.
12. Is there anything else you would like us to know about your health history?
The answer should be a multi line text input.