Medical History Questionnaire Template
The Medical History Questionnaire is a free survey template with 7 questions, 4 of them required. Preview every question on this page without an account, then copy it into Survtapp, change any wording, and start collecting answers on the web or on a tablet.
Already have an account? Sign in to add it.
What is in the Medical History Questionnaire template?
The Medical History Questionnaire template holds 7 questions, 4 of which must be answered before it can be submitted and 3 of which are optional. Between them they capture short typed answers, a date, yes-or-no answers, longer written comments and multi-select answers.
Broken down by field type, the Medical History survey is 2 comment boxes, 2 pass/fail checks, 1 choice questions and 1 date fields.
The 1 choice question in the Medical History survey between them offer 6 preset answers, and every one of those labels is editable — the wording listed below is a starting point, not a fixed list.
When should you use the Medical History Questionnaire template?
The Medical History Questionnaire is filed under “Healthcare”, “History” and “Intake”, in the Healthcare & Medical part of the library, where it is aimed at teams standardising something people were doing on paper. Gather a patient’s medical history ahead of a consultation.
Surveys get answered wherever the respondent already is — a link in an email, a QR code on a receipt, a tablet handed across a counter, or a kiosk-locked device left on a stand. At 7 questions, only 4 of them required, the Medical History survey is short enough to finish in one sitting, which is what keeps completion rates up.
Does the Medical History Questionnaire work offline?
Yes. Once the Medical History Questionnaire is published, the 7 fields and every answer option are stored on the device, so the survey opens and completes with no connection at all. Each response is written to the device first and queued; when signal returns it syncs on its own, keeping the time it was actually captured rather than the time it uploaded.
Because all 7 fields in the Medical History Questionnaire are text and choice inputs, a queued response is tiny and syncs the moment any connection appears — a shared hotspot is plenty. Kiosk mode locks a tablet to this survey alone, so the next person cannot wander into anything else.
How do you customise the Medical History Questionnaire template?
Open the Medical History survey in the builder and all 7 questions land as editable fields — nothing is locked to the template. Rewrite the wording, drag fields into a different order, flip any of the 4 required fields to optional (or the other way round), and add anything missing from the 20+ field types in the builder.
The Medical History survey's 6 preset answers are the fastest thing to make your own: swap in your own product names, sites or departments and it reads as if you wrote it from scratch.
The Medical History Questionnaire runs on a single screen as it stands. Add a page break to split its 7 fields across several, or conditional logic to hide fields that an earlier answer has made irrelevant.
Nothing about the Medical History Questionnaire stays Survtapp-branded, either: your logo, your colours and your own URL slug replace ours, so the 7 fields you publish read as part of your own site rather than as a template someone downloaded.
What happens to the responses you collect?
Every response from the Medical History survey lands in one place with its timestamp, the agent who collected it and, where the device allows, where it was captured. From there each of the 1 choice question gets a bar or pie breakdown, pass and fail counts are totalled per check and written comments are listed in full rather than summarised away.
Export the lot to CSV, Excel, JSON or PDF whenever you want it elsewhere, or set a trigger so a response from the Medical History Questionnaire emails the right person the moment it arrives. Data is held in Canada, the responses stay yours, and you can export or delete them at any time.
What are the 7 questions in the Medical History Questionnaire?
Here is every field in the order a respondent meets it, with the answer type it uses. Nothing here is fixed — the list is where you start, not what you are stuck with.
- 1
Full Namerequired
Short text
- 2
Date of Birthrequired
Date
- 3
Do you currently take any prescription medication?required
Yes / No
- 4
If yes, please list your medications
Long text
- 5
Have you ever been diagnosed with any of the following?
Multiple choice — Diabetes, Cancer, Heart disease, Stroke, Mental health condition, None
- 6
Do you have any known allergies?required
Yes / No
- 7
Family medical history (optional)
Long text
How do you start using the Medical History Questionnaire?
Preview it. Read all 7 questions in the Medical History Questionnaire on this page. No account is needed to preview a template.
Copy it into your account. Create a free Survtapp account and use the template. The Medical History Questionnaire arrives as an editable survey, not a locked copy.
Make it yours. Rewrite the wording, reorder the Medical History survey's 7 fields, adjust which of the 4 required ones stay required, and apply your logo and colours.
Publish and collect. Share a link or QR code, or open the Medical History Questionnaire on a tablet in kiosk mode. It collects responses offline and syncs when the device reconnects.
Already have an account? Sign in to add it.
How will the Medical History Questionnaire look to the person filling it in?
This is the live preview, rendered with the same field widgets the published survey uses. It is read-only here, and your own logo and colours replace ours once it is in your account.
Which templates are like the Medical History Questionnaire?
These share a tag with it in the free library, so they tend to suit the same job. Every one is free to preview without an account.
- Patient Intake FormCollect essential patient information before an appointment.
- Patient Satisfaction SurveyMeasure patient experience across care, wait times, and communication.
- Telehealth Visit Feedback SurveyCollect feedback on virtual appointments and video call quality.
Or browse every free form template, or just the ones tagged Healthcare.
Questions, answered plainly
How many questions are in the Medical History Questionnaire template?
The Medical History survey has 7 questions, 4 of them required and 3 optional. You can add, remove or reorder any of them once the template is in your account.
Is the Medical History Questionnaire template free to use?
Yes. All 7 questions in the Medical History survey are free to preview here with no account, and the template is free to copy into Survtapp. A free account is enough to customise and publish it; the pricing page lists what each plan includes.
Can I change the questions in the Medical History Questionnaire?
Yes — all 7 fields in the Medical History Questionnaire are editable. Rewrite any question, relabel any of the 6 preset answers, change which fields are required, reorder them, and add fields from the 20+ types in the builder.
Does the Medical History Questionnaire work without an internet connection?
Yes. The Medical History survey and all 7 of its fields are cached on the device, so it opens and completes offline. Each response queues locally and syncs automatically when the connection returns, keeping its original capture time.
What devices can the Medical History Questionnaire be filled in on?
Any modern browser, plus the Survtapp iOS and Android apps. The Medical History survey's 7 fields can run on a shared kiosk-locked tablet, on a link people open on their own phone, or behind a QR code on a poster or a receipt.
Who can see the responses collected with the Medical History Questionnaire?
Only the people in your account you give access to, per their role. Every answer to the Medical History survey's 7 fields is stored in Canada, is never sold, and can be exported to CSV, Excel, JSON or PDF — or deleted — at any time.