Health History Survey Template

Use this template to gather essential information about a patient’s medical background, demographic data, lifestyle and more.

Health History Survey Template

Health History Survey

A Health History Survey is a list of questions use to gather comprehensive background medical information about a patient. Essential topic areas are included in this template, such as demographic information, personal medical history, family medical history and relevant questions about the patient’s lifestyle. A Health History Survey is a key tool for doctors and other medical personnel to gather data about their patient’s medical history. A comprehensive and carefully planned survey will give a good understanding about the patient’s health from the past to the current time. The data entered into the survey can be passed on to specialists or other medical team members so that each person treating the patient has the data at their fingertips and does not need to ask the patient the same questions. Together with examination and test results, the Health History Survey is a vital component in enabling a precise diagnosis and planning an effective treatment plan. Gathering Health History data can save lives too – finding out about allergies before beginning treatment can be life-saving.

How do we gather health history data?

Health history data can easily and efficiently be gathered in the form of a survey as demonstrated above.

The data needed to obtain a clear picture of the patient’s medical history is a combination of quantitative and qualitative data. Closed questions with limited choices should be used when quantitative data is needed. Use these types of questions where possible as it makes the survey quicker for the patient to complete, leading to fewer drop-outs and more completed surveys.

Where more detailed information is required, such as a list of medications taken, or past medical procedures, use open-ended questions with a comment box.

How can I make the Health History Survey more user-friendly?

For an optimum user experience, make sure to use logic so patients only need to answer the questions that are relevant to them. Try out the survey template above and you will see that certain questions are displayed only when a specific answer is selected, such as hospitalization details are only requested for those who answer that they have been hospitalized in the past.

Include a progress bar so respondents can see that the survey is not overwhelmingly long and will be motivated to complete it.

How do I create a Health History Survey?

The quickest and easiest way to create a Health History survey is to sign up to Checkbox and use the template we’ve provided. Import the ready-made survey with all questions you can see above, including show question logic into your account, adjust to your requirements – add or delete questions as needed, and you’re ready to go!

Start your free trial on–no credit card required.

Check out more
Survey Templates


Mental Health Survey Template

Collect mental health related feedback via a Checkbox survey to drive meaningful mental health related improvements.


Health Outcome Survey Template

Better understand patients' satisfaction by running a dedicated health outcome survey in Checkbox.


Health Related Behaviors Survey Template

Better understand patient behavior and link insights to health outcomes with a Checkbox survey

Why Checkbox?

No-Code Editor

Get started in minutes with Checkbox!

Dynamic User Profiles

Create the right surveys, for the right users, at the right time!


Manage surveys and send them to users via email, text, website links and more!

Security & Permissions

Advanced Role-Based Access Control settings to ensure the right access for any needs!

Analytics & Reporting

Understand the feedback and share the insights across your organization.

Branded Look & Feel

Create customer experiences that are in-line with your brand's look & feel.

Get a comprehensive overview in our live demo

Checkbox develops affordable, feature-rich survey software for organizations, teams, and individuals

Survey Software