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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.


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.

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.

ヘルスケア調査

医療検査サービス調査テンプレート

21 質問

診察の機能、および現在のサービスの顧客の態度の望ましさのための医療サービス評価調査。

ヘルスケア調査

ヘルスケア意識調査テンプレート

44 質問

品質、手頃な価格、可用性、および顧客の嗜好に関する病院やヘルスケア世論調査。

ヘルスケア調査

医師・プラクティス調査テンプレート

47 質問

医師は、提供病院やサービスの評価を提供し、調査を実践します。