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.
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What is your Gender? Which age bracket do you fall in? Please select your ethnicity. Please select your marital status. Please select if you have the following conditions. Select all that is applicable. When did you have your last physical examination? Please list any surgeries you have had in the recent past Please select your most recent immunizations. Please select all that is applicable. Have you had any of the following tests done, please select if known: Do you smoke or use any tobacco products? Do you consume Alcohol? Is there any unusual symptoms you have noticed recently? If yes, please specify. |