Medical History Questionnaire
An encrypted standalone medical history questionnaire for healthcare providers — conditions, medications, allergies, surgical history, family history and lifestyle, all secured end-to-end.
About this template
This template provides a standalone structured medical history questionnaire. Unlike a general intake form, it focuses exclusively on clinical history — past and current conditions, medications, allergies, surgical history, family history, and key lifestyle factors. All data is encrypted end-to-end.
What it collects
- Patient identification and date of birth
- Past and current medical conditions (multi-select)
- Current medications, dosages and frequency
- Known allergies to drugs, food or environment
- Previous surgeries and hospitalisations
- Family medical history
- Smoking, alcohol and exercise habits
Encrypted by default
Medical history is special-category personal data under GDPR Article 9 and the Swiss nFADP. End-to-end encryption ensures submissions are readable only by your practice — not the platform, not email servers.
How to use it
Use this template
Click 'Use template' to create a copy in your dashboard.
Adapt to your specialty
Add specialty-specific conditions to the multi-select lists or extend family history fields.
Send before a scheduled review
Use it for periodic health reviews, pre-operative assessments, or specialist referrals.
Why a structured medical history questionnaire matters
Medical history gathering is one of the most error-prone steps in clinical care — not because clinicians are careless, but because verbal recall under time pressure is unreliable. Patients forget chronic conditions, omit long-term medications they consider 'just supplements', and underreport family history because they did not know to ask relatives. A structured questionnaire given ahead of the appointment forces systematic recall in a low-pressure environment.
For specialist referrals and pre-operative assessments, a complete structured history also reduces liability: the referring clinician has documented what they knew at time of referral, and the receiving specialist has a complete picture before they see the patient.
What a medical history form should include
- Current conditions — all active diagnoses
- Past conditions — resolved diagnoses still clinically relevant (e.g. cancer in remission)
- Current medications — including over-the-counter drugs, vitamins, and supplements
- Allergies — drug, food, and environmental, with reaction type if known
- Surgical history — procedures and approximate dates
- Family history — first-degree relatives and their conditions
- Lifestyle — smoking, alcohol, exercise, diet (risk factors for many conditions)
Medical history data and GDPR / Swiss nFADP compliance
A medical history questionnaire captures some of the most sensitive personal data that exists. Under GDPR Article 9 and the Swiss nFADP it is special-category data requiring explicit consent, appropriate technical security, and a retention and deletion policy. The data controller (your practice) is responsible for ensuring only authorised personnel access the data. End-to-end encryption means the questionnaire is encrypted before leaving the patient's device and decryptable only by your practice — closing the most common breach vectors.
Verbal history vs structured digital questionnaire
| Verbal history | Structured digital questionnaire | |
|---|---|---|
| Completeness | Recall under time pressure | Patient recalls at home, checks records |
| Consistency | Depends on who asks what | Same questions every time |
| Documentation | Clinician notes, subjective | Patient's own words, structured |
| Security | Notes in unprotected systems | Encrypted, access-controlled |
Common mistakes to avoid
- Asking only about 'medications' — patients often omit OTC drugs and supplements unless explicitly prompted.
- Collecting family history without asking about specific conditions (cancer, heart disease, diabetes).
- Not asking about allergies to contrast media or latex for relevant procedures.
- Storing completed questionnaires in unencrypted email or shared drives.
Frequently asked questions
How is this different from the New Patient Intake form?
The New Patient Intake form covers the full first-visit administrative and clinical picture. This questionnaire focuses solely on clinical history — it's designed for periodic health reviews, pre-operative assessments, or specialist referrals where you need a detailed history update without repeating administrative intake.
Can I use this as a pre-operative questionnaire?
Yes. It covers the key anaesthetic risk factors — cardiovascular conditions, respiratory conditions, current medications and allergies. You can extend it with specific fields for the procedure type and ASA classification.
Is patient data encrypted?
Yes. All answers are encrypted in the patient's browser before submission. Only your practice holds the decryption key.
For more, see our use case for healthcare practices, our guide to clinical data privacy, and our comparison of form tools for medical history collection.