Patient health history questionnaire

We'd like to get straight to the point during your appointment, so we can be as helpful as possible.First, what's your full name?What's your date of birth?What is the reason for your upcoming visit?Are you under a physician's care right now?What's the reason for that?Have you recently been hospitalized?What was the reason for your hospitalization?Are you currently taking any medication?Which one/s?Thanks for your time. We'll see you at your next appointment.

Collect up to 3.5x more data with Typeform

No more filling out forms in the waiting room

Updating your health history should be hassle-free. Let your patients fill out a quick questionnaire before their appointments. This will allow doctors to better prepare possible treatments, and focus patients on one thing at a time.

With Typeform, you can customize everything

Change text, colors, and even logos to match the look and feel of your brand. Then embed forms smoothly onto web and email.

Make forms feel effortless to fill out. Pace questions, call people by their name, and adapt the flow based on the data they share.

Stay efficient by connecting forms to your workflow. Typeform integrates with 300+ tools including Slack, Zapier, and HubSpot.

Patient health history questionnaire FAQs:

Instead of a page full of cumbersome questions, boxes too small to write in and confusing wording, this questionnaire asks your patients one question at a time—the same way you would face-to-face. This helps them to focus and give better answers, for a stress-free process. So it’s a better experience for them, and better for you as you’ll get the info you need to provide a helpful and efficient service.

Before you send out your form, there are two things you should do:

Set up a BAA (Business Associate Agreement) with us

Typeform is a HIPAA-compliant company, so all the healthcare-related info you process with us is legally airtight. But for you to be 100% HIPAA compliant, you’ll first need to set up a BAA. To do this you would need to talk to us about our enterprise plan, which you can do by filling out this Typeform, or contacting your Typeform account manager.

Check the local data collection laws

Data collection laws aren’t a one-size-fits-all thing—especially when there’s sensitive medical info involved. So before hitting share, seek advice from a local lawyer to make sure you’ve covered everything.