Sample Medical History Questionnaire
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3Sample Medical History Questionnaire
Name
________________________________________________________________________
Last
First
Middle
Date of Birth ________________ Sex ______
Address
________________________________________________________________________
Emergency Contact ___________________________ Phone (______) _____________
Please circle “YES” or “NO” and provide additional details where requested on all three
sides of this form.
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?
NO
YES
(list)
______________________________________________________________
2. Do you take any prescribed medication on a permanent or semi-permanent basis
(steroids, anti-inflammatories, antibiotics, insulin, etc.)?
NO
YES
(list and give reason)
_______________________________________________
3. Have you ever had an epileptic seizure?
NO
YES
4. Have you ever been told by a doctor that you have epilepsy?
NO
YES
(list any medication)
________________________________________________
5. Have you ever been treated for diabetes?
NO
YES
(list any medication)
________________________________________________
6. Have you ever been told by a doctor that you were anemic?
NO
YES
When? _____________________ What treatment? ___________________
7. Have you ever been told by a doctor that you have sickle cell anemia?
NO
YES
8. Do you have or have you ever had high blood pressure?
NO
YES
(list any medication)
________________________________________________
9. Do you have, or have you ever had, the following diseases?
Heart disease (heart murmur, rheumatic fever, other)
NO
YES
(give name and date)
_________________________________________________
Lung disease (pneumonia, other)
NO
YES
(give name and date)
_________________________________________________
Kidney disease (infections, other)
NO
YES
(give name and date)
________________________________________________
Liver disease (mononucleosis, hepatitis, other)
NO
YES
(give name and date)
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Parent category: Medical