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Questionnaire template

Personal Health History

Collects patients' background, medications, allergies, long-term conditions, lifestyle habits and family health history.

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Healthcare · Mental health. All Healthcare templates

Questions in this template

About You

  1. Thank you for completing your health history. It takes about ten minutes and helps your care team tailor your treatment.

  2. What is your gender?

    Choose one:

    • Female
    • Male
    • Another gender
    • Prefer not to say

  3. How old are you?

    A number from 0 to 120

  4. Do you currently smoke or use any tobacco products?

    Choose one:

    • Yes
    • No

  5. How often do you drink alcohol?

    Choose one:

    • Never
    • Rarely
    • Occasionally
    • Frequently
    • Daily

Medications and Allergies

  1. Do you regularly take any medicines or supplements?

    Choose one:

    • Yes
    • No

  2. Please list each medicine or supplement and how much you take.

    Condition: Only for those who take medication

    Open answer

  3. Do you have any known allergies, for example to medicines, foods or latex?

    Choose one:

    • Yes
    • No
    • Not sure

  4. What are you allergic to, and what reaction do you have?

    Condition: Only for those with known allergies

    Open answer

Long-Term Conditions

  1. Has a doctor ever told you that you have any of these conditions? Select all that apply.

    Choose any that apply:

    • Diabetes
    • Heart disease
    • High blood pressure
    • Asthma
    • Cancer
    • None of these

Daily Habits

  1. How often do you do physical exercise?

    Choose one:

    • Never
    • Rarely
    • Occasionally
    • Regularly
    • Daily

  2. On a typical night, how many hours do you sleep?

    A number from 0 to 24

Family Health History

  1. Have any of your parents, brothers or sisters had any of these conditions? Select all that apply.

    Choose any that apply:

    • Diabetes
    • Heart disease
    • High blood pressure
    • Cancer
    • Mental illness
    • None of these