Medical History Questionnaire
Medical History Questionnaire
Please fill out this form completely to provide your medical history for evaluation and treatment purposes.
Personal Information
Name
Date of Birth
Address
Phone number
Emergency Contact
Name
Relationship
Phone number
Medical History
Do you have any existing medical conditions?
If yes, please specify:
Are you currently taking any medications?
If yes, please list:
Do you have any allergies?
If yes, please specify:
Have you had any surgeries in the past?
If yes, please provide details:
Do you have a family history of any major illnesses?
If yes, please specify:
Lifestyle Information
Do you smoke?
If yes, how many per day?
Do you consume alcohol?
If yes, how often?
Do you exercise regularly?
If yes, how often?
Additional Information
Please provide any additional information regarding your health that may be relevant
Signature
Name:
Date:
Questionnaire Templates @ Template.net
Thank you for submission!
We appreciate you taking the time to submit.
Create free forms at Template.net
