About this template
A health history questionnaire is an essential tool for gathering comprehensive patient information, including past medical conditions, surgeries, current medications, drug allergies, and daily lifestyle habits. Whether you operate a private medical practice, a specialized clinic, or mental health counseling services, collecting accurate medical data before an appointment ensures safer and more effective patient care.
Doc2Form allows you to transition away from messy paper intake sheets and manual data entry. By turning this template into a Google Form, you can seamlessly collect health histories directly from any device—whether patients fill it out at home or in your waiting room. All responses automatically populate in a connected spreadsheet, making it simple to review patient details, organize medical records, and integrate findings into your practice workflow.
Use this questionnaire to save valuable time during consultations, reduce administrative friction, and establish a clear, organized digital record for every new patient who walks through your doors.
Key features
- Collect complete medical history and current medication details instantly.
- Streamline patient intake before the first appointment.
- Gather allergy and past surgical records in one organized place.
- Easily accessible on mobile phones, tablets, and computers.
- Automatically store and organize responses in Google Sheets.
Use cases
- New patient onboarding for private medical and dental practices.
- Initial health screenings for physical therapy and wellness clinics.
- Pre-appointment intake for mental health counselors and therapists.
What this form collects
- Patient Full Name (Short answer)Enter your first and last name.
- Patient Gender (Dropdown)Select the option that best describes your gender identity.
- Date of Birth (Date)Enter your birth date.
- Patient Height (cm) (Short answer)Enter your height in centimeters.
- Patient Weight (kg) (Short answer)Enter your weight in kilograms.
- Email Address (Short answer)Enter the best email address for appointment follow-ups.
- Reason for Visit (Paragraph)Briefly describe the primary symptoms, concerns, or reason for today's appointment.
- Drug Allergies (Paragraph)List any known allergies to medications, or write 'None'.
- Past Medical Conditions (Checkboxes)Select any major medical conditions you have had in the past.
- Other Illnesses or Chronic Conditions (Paragraph)List any other chronic illnesses or ongoing health issues not mentioned above.
- Surgeries and Approximate Dates (Paragraph)List any past surgeries and when they occurred.
- Current Medications (Paragraph)List all prescription medications, over-the-counter drugs, vitamins, and supplements you currently take.
- Exercise Frequency (Multiple choice)How often do you engage in physical exercise?
- Diet Plan Status (Dropdown)Do you follow any specific diet plan?
- Alcohol Consumption (Multiple choice)How often do you consume alcoholic beverages?
- Caffeine Consumption (Multiple choice)Do you regularly consume caffeine (coffee, tea, energy drinks)?
- Smoking Status (Multiple choice)Select your current tobacco or nicotine use status.
- Additional Medical History Comments (Paragraph)Is there anything else regarding your health history that your provider should know?
FAQ
How do I use this health history template with Doc2Form?
Doc2Form instantly converts this structured template into a ready-to-use Google Form in seconds, allowing you to share it with patients immediately.
Can I customize the questions for my specific medical practice?
Yes! Once generated in Google Forms, you have full freedom to add, remove, or modify any questions to fit your specialty.
How do patients submit their health history?
You can send patients a secure link via email or text message before their visit, or let them complete the form on a tablet in your office waiting room.
Where are patient responses stored?
All submissions are securely saved in your Google Drive and organized within a connected Google Sheet for easy review by your clinical team.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.