Patient Health History Questionnaire Forms

Patient’s health is the main concern of the hospital and more specifically saying the concern of health providers. It always gives as immense pleasure and happiness to the health providers when they successfully treat a patient whether in an emergency or in a prolonged disease.

Why a patient’s health questionnaire is important?

Successful patient management always begins with the basic and smallest steps which must be taken efficiently. When the initial steps are performed well, they always guide to a better establishment of understanding of the disease and help the physician to make a successful and effective plan for management of the disease.

Health care always begins with history taking. A good history helps us in getting the exact idea of the patient’s current situation and how this situation is based on the previous history of the patient with respect to health.

One such basic step in history taking is the assessment of the patient through a questionnaire. This questionnaire is designed to dig out the basic health issues which lead to serious diseases to the patients.

Patient health history questionnaire is required to be filled by doctors whenever there is a patient coming for the first appointment. The purpose of this questionnaire is to know about the health history of the patients and to get an 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 the 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 include 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 have been phenomenal and been comprehensively studied in practice settings of physicians. But there has not been much research done on populations that are relevant to the 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 no restriction in the content of these questionnaires but the above-mentioned details must be mentioned.

The patient health history form can have other names like medical history form or family health history form.

Here is a preview of the 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


Types of patient health questionnaires

There are a number of different types of patient health questionnaires which are aimed to assess different aspects of health.

Mental health assessment questionnaire

Mental health is mostly assessed with the help of patient and doctor interaction and a couple of questionnaires. There are different types of questionnaire to know different aspects of the mental health of the patient.

Some questionnaires are designed to diagnose the depression and the degree of depression in the patients while some aim to dig out any psychotic illness in the patients. All the questionnaires always contain a section in which some questions are asked about the patient’s idea of his own health.

Pain assessment questionnaires

Another form of the patient health questionnaire is the assessment of the pain. There are many types of pain and a questionnaire is filled to know the exact type of pain a person is going through. Some questionnaires may have pictorials to pinpoint the sites of pain.

Patient’s general health assessment questionnaires

This is the simplest and most common form of patient health assessment questionnaires. Knowing the general health of the patient is the main aim of such forms. These are in fact the true form of patient health history questionnaire because we ask about the patient’s healthy or unhealthy habits as well. These questionnaires generally cover mental health questions as well.

  1. In these questionnaires, the past medical and surgical history is also mentioned along with a history of allergies and medication.
  2. They also include some questions about habits and lifestyle in which patient is inquired about the habits of smoking, sleeping, and general routine and lifestyle.
  3. Patient’s dietary habits are necessary to ask in these questionnaires because this history directly corresponds and gives information about the present condition of the patient.
  4. Exercise and physical activity level are also assessed in the forms. Some integral parts of the personal life may also be inquired just to know how mentally stable the patient is.

Simi Karton

Dr. Simi Karton currently resides in Los Angeles with her husband. This website is a voluntary work of Dr. Karton to provide people with useful health-related information with a straightforward approach.

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