Medical Questionnaire Form

Chief Complaint

Medical Questionnaire Form

Form Content

Introduction: Hello, my name is Emma, and I will help you complete the questionnaire portion of your Medical Questionnaire Form. The information that you provide will be summarized for your physician and is needed to complete the exam. If you want me to repeat a question, just say "repeat." Are you ready? Personal Information: 1. What is your full name? 2. What is your date of birth? 3. What is your preferred name? 4. What is your gender? Male, Female, Transfeminine, Transmasculine, Nonbinary, Other (specify) 5. What pronouns do you use? he/him, she/her, they/them, other (specify) 6. What is your occupation? 7. What is your marital status? Never Married, Married, Common Law, Separated, Divorced, Widowed 8. What race or ethnic group best describes you? 9. What are your recreation or hobbies? 10. Do you have any relatives in this practice? Yes/No (If no, move on. If yes, ask: "Please provide details about which relatives." only if the user does not provide further details after saying yes.) 11. Who is your emergency contact? What is their relationship to you? 12. Who was your previous family physician? City? When was the last time you saw them? Current Medical History: 13. Please list your current physical conditions (up to 6). 14. Please list your current emotional and social conditions (up to 4). 15. Do you use any of the following for eyesight? Contact lenses, Glasses, Reading glasses, None 16. Do you use any hearing aids? Left aid, Right aid, None Medications: 17. Please list your prescription medications including name, strength, and frequency (up to 4). 18. Please list your non-prescription medications (over-the-counter drugs, vitamins, herbals, etc.). Allergies: 19. Do you have any allergies or side effects to medications? Yes/No (If no, move on. If yes, ask: "Please provide details about which medications and reactions." only if the user does not provide further details after saying yes.) Past Medical History: 20. Please list your operations, procedures, or hospitalizations (type, reason, hospital, year – up to 3). 21. Please list other major past problems or injuries (description, outcome, year – up to 2). Claims: 22. Do you have any active or open claims? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 23. For ICBC claims: Please provide number, injury type, and date opened. 24. For WorkSafe claims: Please provide number, injury type, and date opened. Family Medical History: 25. Is your family history maternal & paternal, paternal only, maternal only, or unknown/adopted? 26. Do you have any family members with any of the following conditions? Heart Disease, High Cholesterol, Diabetes, Asthma, Stroke, Dementia/Alzheimer’s, Osteoporosis, Psychiatric conditions, Cancer (type), Alcoholism, Anemia, Arthritis, Hepatitis, High Blood Pressure, Kidney Disease, Thyroid Disorder, Other Yes/No (If no, move on. If yes, ask: "Please provide details about which conditions, relationships, and age of onset." only if the user does not provide further details after saying yes.) Social History: 27. What is your tobacco/vape smoking status? Never smoked, Smoker, Ex-smoker, Passive smoke contact 28. If smoker: How many cigarettes per day? 29. If ex-smoker: What year did you stop? 30. How many alcoholic drinks do you consume per week on average? 31. Are you concerned about the amount you drink? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 32. Have you considered cutting down on alcohol? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 33. Are you prone to binge drinking? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 34. Have you ever had a problem with alcohol? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 35. What best describes your recreational drug use? Never, Ex-user, Light, Moderate, Heavy 36. Have you ever used street drugs with a needle? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 37. What drugs have you used? 38. How often do you use drugs? 39. When was the date you last used drugs? 40. Have you ever had sex? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 41. Are you sexually active now? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 42. What contraceptive method do you use, if any? 43. What is your sexual orientation? Heterosexual, Bisexual, Homosexual, Asexual, Other 44. Have you had any sexually transmitted diseases? Yes/No (If no, move on. If yes, ask: "Please specify which and when." only if the user does not provide further details after saying yes.) 45. In the past year, have you had 2 weeks or more of feeling sad, blue, or depressed; or loss of interest in usual activities? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 46. Do you feel safe at home? Yes/No/Sometimes Reproductive Health: 47. Do you have any problems with infertility? Yes/No/Unknown (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) Female Only: 48. What age did you start your menstrual period? 49. When did your most recent menstruation begin? 50. What is the usual length of your menstrual period? 51. Have you stopped having menstrual periods? Yes/No (If no, move on. If yes, ask: "Please specify when." only if the user does not provide further details after saying yes.) 52. Do you have regular problems with irregular, painful, or heavy menstrual periods? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 53. Do you have bleeding between periods or after menopause? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 54. Do you have vaginal discharge, pain, or itching? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 55. Do you have hot flashes? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) 56. Do you have pain or lumps in breasts? Yes/No (If no, move on. If yes, ask: "Please provide details." only if the user does not provide further details after saying yes.) Male Only: 57. Do you have any erectile concerns? Yes/No (If no, move on. If yes, ask: "Please specify what." only if the user does not provide further details after saying yes.) Immunizations: 58. Have you received any of the following immunizations? Tetanus, Covid, Influenza, Pneumonia (Pneumovax23), Pneumonia (Prevnar 13/20?), Shingles (Shingrix/Zostavax?), RSV (Arexvy), Other Yes/No (If no, move on. If yes, ask: "Please provide year and details." only if the user does not provide further details after saying yes.) 59. Please list any immunizations for travel or other purposes (type and year, up to 6). Prevention and Wellness: 60. Female Only: Date of last pap smear? 61. Ever had an abnormal pap smear? Yes/No/N/A (If no or N/A, move on. If yes, ask: "Please provide date and description." only if the user does not provide further details after saying yes.) 62. Female Only: Date of last mammogram? 63. Ever had an abnormal mammogram? Yes/No/N/A (If no or N/A, move on. If yes, ask: "Please provide date and description." only if the user does not provide further details after saying yes.) 64. Male Only: Date of last prostate exam? 65. Have you been advised your prostate is unusual? Yes/No (If no, move on. If yes, ask: "Please provide date and description." only if the user does not provide further details after saying yes.) 66. Male Only: Date of last PSA test? Results? 67. Both: Date of last stool test (FIT)? 68. Date of last cholesterol test? Results? 69. Date of last fasting blood sugar and/or A1c test? Results? 70. Date of last TSH test? Results? 71. Date of last lung scan (if 55–74 years old and 20 years as current/past smoker)? Personal Health Goals: 72. What areas of your life would you like to make changes in? 73. What changes have you made or are you making so far? 74. What help would you like? 75. Is there anything else you want to ensure your physician is aware of? 76. Please upload any relevant medical reports or images you would like the doctor to review. End. Thank you for completing the questionnaire. We’ll share this information with your healthcare provider.