General Patient Intake Questionnaire

Chief Complaint

General Medical Questionnaire Form

Form Content

Introduction: Hello, my name is Emma, and I will help you complete the questionnaire portion of your General Medical Questionnaire Form. The information that you provide will be summarized for your physician and is needed to complete the exam. We estimate this questionnaire will take around 10 minutes to complete. If you must stop, you can return at a later time to finish. Thank you for booking an appointment at our clinic. To help make your visit as effective and efficient as possible, we kindly ask that you take a few minutes to describe your concerns before your appointment. If you want me to repeat a question, just say "repeat." Are you ready? General Concerns: 1. What is the main concern or reason for your visit? (For example: wrist pain, skin issue, fatigue, etc.) 2. When did the issue start? How has it changed since then? Please include if it came on suddenly or gradually, and whether it's getting better, worse, or staying the same. 3. What makes the symptom better or worse? (For example: movement, rest, medications, time of day, specific activities, etc.) 4. Are you experiencing any of the following associated symptoms? Muscle weakness, numbness, clicking, swelling, stiffness, fever Yes/No (If no, move on. If yes, ask: "Please describe which symptoms and their severity." only if the user does not provide further details after saying yes.) 5. What have you tried so far to manage it? (Any medications, home remedies, physiotherapy, etc.) 6. What are you hoping to get from the visit? (For example: diagnosis, treatment, referral, reassurance, test request, etc.) 7. Please upload any relevant medical reports or images you would like the doctor to review. End. (Show the following information when questionnaire complete) Your answers will help us focus the visit on what matters most to you and may also shorten the time needed in the clinic. We look forward to seeing you soon.