Patient Health History Questionnaire Template

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:

1. Yes
2. No
3. I'm not sure
4. 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:

1. Yes
2. No
3. I'm not sure
4. 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:

1. Yes
2. No
3. I'm not sure
4. 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:

1. Yes
2. No
3. I'm not sure
4. Prefer not to answer

6. Do you have any allergies to medications or food?

The answer should be a single choice:

1. Yes
2. No
3. I'm not sure
4. Prefer not to answer

7. Do you smoke or use tobacco products?

The answer should be a single choice:

1. Yes, daily
2. Yes, occasionally
3. No, never
4. I used to, but I quit

8. Do you consume alcohol?

The answer should be a single choice:

1. Yes, daily
2. Yes, occasionally
3. No, never
4. I used to, but I quit

9. Do you exercise regularly?

The answer should be a single choice:

1. Yes, daily
2. Yes, 3-5 times per week
3. Yes, 1-2 times per week
4. 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:

1. Yes
2. No
3. I'm not sure
4. 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.