Medical History Questionnaire Template

Use this questionnaire to learn about the health of new patients, clients, or employees.

Learn More...

Medical History Questionnaire

Please fill out this medical history questionnaire accurately so that we can give you the best possible service. The information you provide will be kept confidential and is protected by law.

How can we contact you?

Please give us your email and phone number so that we can contact you with any further questions.
Please fix the errors below and submit again
Use this template

A medical history questionnaire is a type of survey that lets you gather vital medical information about your respondents. It is mostly used by medical professionals, insurance companies, and researchers to get to know their clients and/or subjects better. Some employers use them too to learn more about their new employees and ensure their health and safety. Our customizable questionnaire template will allow you to modify it to your needs. Visit our survey templates and form templates for more questionnaires that can help you collect important data from your employees safely and considerately.

A Few Caveats

Medical information is confidential. Once you receive it, you are obligated to safeguard it by various data protection laws, including HIPAA compliance. Depending on your location, you may even be prohibited from asking certain intrusive questions. Please, consult your local laws and regulations before you give out your medical history questionnaire.

What a Medical History Questionnaire Should Include

In general, a medical history questionnaire should include two sections – demographic information and medical history. 

Demographic information is mostly needed for research and statistical purposes. If you don’t find it relevant, you can freely skip this part. Just make sure to get the basic personal information you need to identify the person responding. 

The medical history section aims to fill the gaps that naturally exist when meeting new clients, patients, or employees. It’s there to help you make sure you’re not overlooking any health risks or contributing to them inadvertently. However, here too remember that you’re asking very personal questions, so make sure everything you ask is truly necessary.

Demographic Information

Demographic questions will help you determine which population group your respondent belongs to. Depending on your objective, this information may help you highlight potential health risks and sensitivities or compare and measure accurately.

In general, demographic questions should include some or all of the following: age, gender, occupation, civil status, family status, and level of education. Once again, you should only include the questions you need the answer to. So, if you are focusing on the differences between men and women, you don’t need to ask anything else. On the other hand, you can include additional questions, if they are relevant. For example, race/ethnicity, income, and sex.

Whatever you ask, please keep in mind that these questions may be technical for you, but for your respondents, they can be very sensitive and personal. Be as considerate and inclusive as possible. Try to cover all subgroups and possibilities in your answer options. At the very least, allow your responders the option to check “other” and elaborate.


Medical Information

Now that we have discussed the demographic aspect let’s tackle the core of this questionnaire – gathering essential information about your respondents’ medical history. No matter what you ask, make sure your questions are crystal clear and specific, you don’t want any misunderstandings here. You can ask open-ended questions, however, multiple-choice questions are the gold standard.

There is some basic information every medical history questionnaire should try to obtain. Namely, allergies/adverse responses to medication, any current and ongoing treatments and medications, family health history, prior hospitalizations, and pre-existing conditions (if it is legal to ask). Any further questions can vary according to your needs and focus area.

For instance, if you are a dentist and a new patient has come to get some work done, it makes sense to ask about previous dental work as well as smoking or the use of tobacco products. The goal is to obtain any information that is important to your work and their health and safety. So, ask about the details that could affect these factors.

3 Final Remarks on Building a Medical History Questionnaire

  1. The medical history questionnaire should be concise in order to ensure precision. If you make it five pages long, you won’t get accurate answers. Consequently, focus on the areas that are most important.

  2. When it comes to an important topic like health, small misunderstandings can have a devastating effect. Make sure that any question you ask is simple, clear, and easily understood. Too much medical jargon can confuse your responders, and lead to inaccurate answers.

  3. Last but not least, emphasize privacy to encourage openness and honesty. Sometimes people refrain from sharing vital information because of shame, embarrassment, or fear of judgment. You can’t control what they choose to share, but you can offer a safe nonjudgmental space. If it is clear to your respondents that you are on their side, chances are they’ll be more open with you. Be kind, transparent, and respectful; make it easy for them to trust you, and do your utmost to offer privacy and support.


People who viewed Medical History Questionnaire also viewed

You can easily do it yourself

Sign up free