59 Health History Questionnaire Templates [Family, Medical]

A health history questionnaire is one of the most important self-evaluation tools which every medical institution makes use of. What is a health history questionnaire and what does it contain, let’s find out.

A health history questionnaire is a document filled by doctors and is used whenever a patient first visits a medical institution. The main purpose of a medical history questionnaire is to find out about a patient’s health history and get an idea of his/her health.

The health history questionnaire contains a considerable amount of information about the patient’s health history, including his/her safety and health habits, gender specific medical history, family health history, and other relevant medical information. Following is some of the general patient information revealed by a medical history questionnaire:

  • Name of the patient
  • Gender of the patient
  • Patient’s DOB
  • Occupation
  • Marital status
  • Past doctor (s)
  • Previous examination date

In addition to the above, the personal/general health section of the health history questionnaire lists down childhood illnesses, such as Chicken Pox, Measles, Rheumatic fever, Mumps, Rubella etc. Additionally, this section contains medical illnesses such as Asthma, Bleeding Disorder, Gout, Heart disease, diabetes, generic defects, hypertension, severe infections, Osteoarthritis etc. as well.

Health History Questionnaire Templates

In addition to the list of things mentioned above, other information is also included in a medical history questionnaire. A good way to find out about them is by taking a look at a medical history questionnaire template. Talking about templates, you can create an appropriate medical release form by taking a look at a medical release form template.

Coming back to the topic at hand, not many people argue of the importance of a health history questionnaire. The reason for this is simple: medical history questionnaires have proven their significance and utility in physician practices and medical studies. A medical history questionnaire helps a physician record and document the use of medication, surgery, and the illness history of a patient precisely and accurately.

In addition to helping the physician in his/her practice, the health history questionnaires can be utilized significantly in various medical studies if they are properly and accurately filled by the patients. Though there are no set questions to include in the medical history questionnaire, the aforementioned information must be part be of the questionnaire. At times, a healthy history questionnaire may be referred to as a family medical history questionnaire. Now, let’s discuss the health history questionnaire in a bit more detail.

Health History Questionnaire Structure

A health history questionnaire reveals everything that’s part of a patient health history. What is a patient’s health history? Simply put, it’s a comprehensive appraisal of all factors affecting the health status of a patient. The medical history questionnaire reveals information related to the economic, familial, cultural, and social aspects of a patient’s life. Additionally, it shows the lifestyle of the patient and how it may affect his/her health and well-being. The purpose of designing the health history questionnaire is to see how a patient’s health has changed over the years so that an appropriate, individualized wellness and treatment plan can be designed for him/her. Following is the definition, purpose, and description of a medical history questionnaire.


A collection of information unique to the patient is what a patient’s health history refers to. All relevant history of a patient, including physical, bipographical, emotional, mental, demographic, spiritual, sexual, and socio-cultural information is part of a patient’s health history questionnaire.


By providing them useful information that aids diagnosis, the decisions related to treatment, and the building of rapport and trust between the patient and the medical practitioners, the medical history questionnaire helps both the patients and the healthcare providers. The information provided in the health history questionnaire helps doctors determine the baseline of a patient and what’s normal for him/her.


The use of a health history questionnaire is one of the most common methods of obtaining a patient’s health history. In fact, a medical history questionnaire is the best way to obtain a person’s health history if the person in question is able to communicate effectively. The person or patient in question can provide the relevant information by using his/her previous records, or by contacting previous doctors and other healthcare providers.

A number of factors affect the length and depth of the history-recording process, including the ability or willingness of the patient to contribute information, the purpose of the visit, the environment in which the information is recorded, and the urgency of the condition or complaint. If circumstances allow, the healthy history questionnaire may become a comprehensive appraisal of all factors affecting the health status of a patient. However, in most cases, it’s a review of the most relevant factors.

The health history questionnaire may solely focus on the medical experiences of a patient if there is a requirement for the health history recording process to be shortened. There are a number of ways to organize health histories. Depending on how it performs its day-to-day tasks, the hospital or individual medical practice may use a physical form or computer-based health history questionnaire. Regardless of how their doctor/healthcare provider wants them to complete the health history questionnaire, patients can find out what information they need to provide in the questionnaire by taking a look at a medical history questionnaire template. The demographic data is generally the first thing which a patient is asked for in the questionnaire. Following is the demographic data included in the medical history questionnaire:

  • Patient’s name
  • Patient’s gender
  • Date of birth
  • Living arrangements
  • Family structure
  • Occupation

Once the aforementioned information is gathered, the questionnaire needs to explain in detail the reason for the visit. Often, the reason for the visit is marked as the presenting complaint, or chief complaint, in the medical history questionnaire. Once the reason for the visit is known, the next thing to obtain is a complete picture of the patient’s current medical situation.

For example, if the patient is suffering from pain, the health history questionnaire should record aspects such as the pain’s intensity, location, associated symptoms, duration, precipitating factors, relieving factors, and aggravating factors. Often, the name given to the complete picture of the patient’s current medical situation is the history of present illness (HPI).  A useful way of collecting the relevant medical information in an organized manner is by reviewing the current and past medical experiences of a patient by asking him/her a series of questions.

Generally, the aforementioned series of questions proceed from general to specific information. In order to determine the relevance of events to the current condition or the relevance of past illnesses, a complete record of relevant dates is required. A head-to-toe order is what the aforementioned review process typically follows. Following are categories of conditions reviewed in the health history questionnaire:

  • Nervous system including central and peripheral components
  • Cardiovascular
  • Mental including psychiatric issues
  • Head, eyes, ears, nose, throat
  • Gastrointestinal
  • Endocrine
  • Respiratory
  • Musculoskeletal including joints
  • Integumentary
  • Genitourinary

In addition to the above, the review of the current and past medical experiences includes information such as medications taken by the patient, illnesses, allergies, pregnancies, procedures, and hospitalizations. Also, it may include environmental factors, such as health maintenance habits and exposure to chemicals. Immunizations or breast/testicular self-examination are some examples of health maintenance habits.

Patient History Questionnaire

Following are some examples of the questions that patients may be asked in the questionnaire:

  • Do you have any trouble hearing?
  • How are your ears?
  • Have you ever experienced problems with your hearing or your ears?

If the patient reveals that he/she has had a history of hearing problems, then further questions related to the procedures, surgeries, medicines or associated problems of the current/past condition will be asked in the questionnaire. Taking a look at a medical history questionnaire template is a good way to find out what’s included in a medical history questionnaire. Talking about templates, you can easily create an emergency contact form or a medical consent form by taking a look at their respective templates.

In addition to the demographic data, the review of current and past conditions, and the chief complaint, a health history questionnaire reveals the following factors related to the patient:

  • Mental or emotional illnesses
  • Beneficial habits, such as exercise
  • Detrimental habits, such as smoking
  • The family and social life of the patient
  • Aspects of spirituality, culture, and sexuality
  • The patient’s family medical history

All health history questionnaires are not the same. Medical practices customize the questionnaire based on the culture, age, attitude, and the educational level of the patient. As mentioned earlier, a medical history questionnaire is often referred to as a family medical history questionnaire. Wondering what a family medical history questionnaire is and what does it contain? Let’ take a look.

Complete Health History Questionnaire

Family Medical History Questionnaire

A family medical history questionnaire helps you find out what conditions run in your family and records any health conditions and treatments you or other people in your family have had. Also, it may record the conditions and treatments of your spouse and his/her family. This allows you to find out the health problems that run in your family and may affect your unborn child.

Recording the health history of your family can help you make important decisions related to your health. Even before your baby is born, you can learn about his/her health by looking at your family health history. Also, by providing the information related to your family health history to your doctor via a family medical history questionnaire, you can make it easy for him/her to recommend appropriate treatments and care for your baby.

How information is recorded

The family medical history questionnaire is one of the most common ways of providing the doctor/healthcare provider your family health history. To obtain the information to be filled in the questionnaire, send a copy of the questionnaire to relevant family members and ask them to provide the required information. Ensure that they provide you with as much family health history as possible. The best thing to do is send the questionnaire to everyone in your family, and your spouse’s family. Also, you must do the following things when filling out the questionnaire:

  • You see instructions at the beginning of each section. Make sure that you read them. By reading the instructions, you’ll make it easily for yourself to fill out the questionnaire
  • It is important that you take your time to fill out the questionnaire. There are likely to be some questions whose answers you don’t know. Talk to your spouse and family before answering such questions
  • It is important that you focus only on blood relatives, such as your siblings, parents, and grandparents. No need to include distant relatives or step siblings

It is important that you keep constant track of your family health history. Make necessary additions to your family health history as your family grows/changes. To ensure that you fill the family medical history questionnaire appropriately, maintain copies of:

  • Current and past medications
  • Test results
  • Medical exams including dates and treatments

A great time to obtain the information required to complete the family medical history questionnaire is to do so at the time of a family gathering. So, the next time you’re at a family event, make sure to ask your family members about their health histories.

Final word

A health history questionnaire is one of the best ways to obtain a patient’s health history and get an idea about his/her health. Additionally, the questionnaire can be used to obtain the patient’s family medical history. To know what exactly is included in a health history questionnaire, take a look at a medical history questionnaire template.

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