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Medical History Form Template
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1.
Full name
2.
How old are you?
3.
What is your gender?
Choose
Male
Female
Prefer not to say
4.
Phone number
5.
Email address
6.
Select any conditions that apply to you or members of your immediate family:
[Checkboxes]
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Other
7.
Which of the following symptoms are you currently experiencing?
[Checkboxes]
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
8.
Are you currently taking any medications?
Yes
No
9.
Do you have any medication allergies?
Yes
Not sure
No
10.
Do you currently use, or have you ever used, tobacco products?
Choose
Yes
No
11.
Do you currently use, or have you ever used, illegal drugs?
Choose
Yes
No
12.
How often do you drink alcohol?
Never
Occasionally
Monthly
Weekly
Daily
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