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SURVEY
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Medical History Questionnaire
Gather a patient’s medical history ahead of a consultation.
Log in to use this template
Preview — how respondents will see this form
Full Name
*
Short answer…
Date of Birth
*
Select date…
Do you currently take any prescription medication?
*
Yes
No
If yes, please list your medications
Long answer…
Have you ever been diagnosed with any of the following?
Diabetes
Cancer
Heart disease
Stroke
Mental health condition
None
Do you have any known allergies?
*
Yes
No
Family medical history (optional)
Long answer…