Health history questionnaire template

The health history questionnaire gathers vital information about a patient's personal medical history, family health background, lifestyle choices, and environmental exposures.

It also captures their reproductive and sexual history, and vaccination records, assisting healthcare professionals with indispensable information for accurate diagnosis and effective treatment planning.

Health history survey

Example questions

Demographic Information:

Medical History

1. Previous medical conditions
2. Current medical conditions
3. Medications
4. Allergies
5. Hospitalizations
6. Surgeries

Family Health History

1. Chronic medical conditions in immediate family
2. Family history of early death
3. Family history of genetic disorders


1. Exercise routine
2. Smoking history
3. Alcohol consumption
4. Drug use

Environmental Exposures

1. Occupational exposures
2. Exposure to toxins
3. Environmental allergens

Reproductive and Sexual History

1. Pregnancy history
2. Birth control history
3. Sexual history

Vaccination History

List of vaccinations

Health History Questionnaire Template Builder

LimeSurvey's health history survey builder creates customizable questionnaires that gather valuable information on a patient's medical and family history, lifestyle habits, environmental exposures, and vaccination history, helping healthcare providers deliver personalized and effective treatment.

  • Easy and simple to use
  • Statistics
  • Questionnaire templates
  • GDPR compliance
  • So much more…

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