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General Medical History Questionnaire Template

A printable medical history questionnaire for any clinic that needs a clean baseline: conditions, medications, allergies, surgeries, and lifestyle, in a format you can adapt for your discipline.

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Last reviewed September 2026 · Not legal advice

A baseline every clinic can start from

Most clinics ask the same core questions: what conditions do you have, what do you take, what are you allergic to, what surgeries have you had. A shared baseline saves time, and you can add discipline-specific sections on top.

Keep it accurate by asking returning patients to review it, not to start over. Changes in medication or health are the ones that matter most.

Clinic name · address · phone

General Medical History Questionnaire

Client

Full name

Date of birth

Phone

Conditions

Diabetes
Heart condition
High blood pressure
Bleeding or clotting disorder
Autoimmune condition
Cancer (current or past)
Epilepsy
Skin condition
Mental health condition
None of these

Medications and allergies

Current medications and supplements

Allergies (medications, latex, products)

History

Surgeries and hospitalizations

Pregnant or breastfeeding? Yes No

Smoking / alcohol

Family physician

Consent

InitialsI confirm my answers are accurate and will tell my practitioner of changes.

InitialsI consent to my practitioner contacting my physician if needed.

Signatures

Client / patient signature

Date

Practitioner name and signature

Date

Template from zdrovia.ca/templates/general-medical-history-questionnaire/ · Review with your medical director, regulatory college guidance, and insurer before use.

Send this form before the appointment instead of printing it

Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.

Start free, no card required See how digital forms work →

See how Zdrovia is set up for multidisciplinary clinics.

Frequently asked questions

How often should it be updated?

At every visit for medications, and at least annually for the whole form.

Can I add sections for my discipline?

Yes. The form is a base, and extra sections can go after Consent.

This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.