Health History Survey Questions Template

Health History Questions Survey Template is designed by experts at QuestionPro. This questionnaire is designed to collect first hand information from respondents about their health history, if they have undergone any surgeries or immunization, if they have a habit of smoking or drinking and other important details that can possibly influence their health. This sample survey has 12 questions that can be customized to suit the research needs of a researcher. This form can be used by medical professionals and any researcher who wishes to collect medical/health history information from his/her respondents.

Background and Purpose of Conducting Health History Questionnaire

A lot of reasons can cause someone to fall sick - family traits, virus, stale food or a plethora of other reasons.
It is beneficial for a person to have a doctor who knows about your past illness or your mental state to understand your current illness as there can be a sign of past impression on your current health.
But it isn’t always possible for a family doctor to be a part of the treatment process and hence a health history questionnaire is important.
A health history questionnaire tracks all past illnesses, habits, family health and every relevant piece of medical information that helps medical personnel to make informed decisions about health and aid towards the right treatment.
Medical science is at a pinnacle and there is a cure for almost every ailment provided the right symptoms including the health history are accounted for.

Sample Parameters to be Tracked in a Health History Questionnaire?

Whilst there is no limit to the questions that can be a part of a health history questionnaire, the basic parameters and questions to be covered are personal health history, family health history, health habits and mental health.
You must also keep in mind the sex of the patient while framing the questionnaire. Get your patients to fill out the questionnaire prior to their first appointment and a subsequent questionnaire albeit of recent health prior to every appointment.
QuestionPro has 50+ question types so that each form can be more productive and focused on extensive diagnosis.
This tool makes it easy to manage the health history questionnaire in an easy format without having to look for tools with different functionalities.

Background and Purpose of Conducting Health History Questionnaire

Sample Parameters to be Tracked in a Health History Questionnaire?

Related templates and questionnaires

Medical Examination Services Survey Template

Healthcare Opinion Survey Template

Physician Practices Survey Template

QuestionPro in your language


What is your Gender? Male Female Which age bracket do you fall in? Below 18 years 19-30 years 31-40 years 41-50 years 51-60 years Above 60 years Please select your ethnicity. American Asian Indian European Afro-American Other Please select your marital status. Single Married Separated Divorced Living with Partner Please select if you have the following conditions. Select all that is applicable. Diabetes Heart Disease Kidney Disease Depression Sexually Transmitted Diseases Other When did you have your last physical examination? Less than a month ago A month ago 6 months ago A year ago More than a year ago. Please list any surgeries you have had in the recent past Please select your most recent immunizations. Please select all that is applicable. Tetanus Pneumonia Influenza Hepatitis B Other Have you had any of the following tests done, please select if known: Cholesterol Pap smear/Pelvic Mammogram Blood in stool HIV Colonoscopy Other Do you smoke or use any tobacco products? Yes No Do you consume Alcohol? Yes No Is there any unusual symptoms you have noticed recently? If yes, please specify.