Patient Health History Questionnaire Forms

Patient Health History Questionnaires

Patient health history questionnaire is required to be filled by doctors when ever there is a patient coming for first appointment. The purpose of this questionnaire is to know about the health history of the patients and to get some idea about his health. This questionnaire contains the detailed information about the personal health history of the patient, personal safety and health habits of the patient, male and female related history, family health history and other relevant symptoms and information. General patient information section of patient health history questionnaire include patient name, patient sex, date of birth, marital status, occupation, previous examination date and referring or previous doctor. The personal health history section of this questionnaire included childhood illness (Measles, Mumps, Rubella, Chicken Pox, Polo, Rheumatic Fever or other) and medical illness (Diabetes, Hypertension, Heart Disease, Asthma, Cancer, Genetic Defects, Osteoarthritis, Gout, Epilepsy, Bleeding Disorder, Severe Infections and other).

The utility and significance of patient health history form or health history questionnaire form has been phenomenal and been comprehensively studied in practice settings of physicians. But there has not been much research done in populations that are relevant to practice of physical therapists. The purpose of this questionnaire is to record and document the precision and accuracy of a patient’s illness history, surgery and use of medication. These questionnaires if filled accurately and properly by the patients can be significantly utilized in different studies and are very much helpful in anticipating different outcomes of medication. Generally there is not bounding in the content of these questionnaires but the above mentioned details must be mentioned in the form. The patient health history form can have other names like medical history form or family health history form.


Here is a preview of patient health history questionnaire forms

Questionnaire Form-1  | No. of pages = 4 | Microsoft Word file | Size 238 KB   | Download

Patient Health History Questionnaire Form

Patient health history questionnaire form

Questionnaire Form-2  | No. of pages = 12 | Pdf file | Size 704 KB   | Download

Few snapshots

Patient Health History Questionnaire Form

 Patient Health History Questionnaire Form

 Patient Health History Questionnaire Form