Patient’s Personal and Family Medical History Form (Questionnaire)

What Is Medical History?

A medical history or anamnesis (Greek anamnesis = recalling) is a summary of your symptoms, past diseases, therapies, medical investigations and diagnoses (personal medical history), and chronic diseases running in your family (family medical history), as you reveal them to your doctor (Picture 1).

Picture 1. Collect all important details about your health problem
and reveal them to your doctor

Below questionnaire may help you to recall all details, which may help your doctor to give you a correct diagnosis and treatment.

Medical History Questionnaire

1. Basic Data

Sex, age, height, weight, occupation, marital status.

2. Current Symptoms

a) Your main current symptom (the one you have right now) with exact description:

  • What exactly is your main symptom and how severe it is: does it prevent you to eat, sleep, walk, etc.?
  • Where exactly does the symptom appear, and, if pain, does it radiate to other parts of the body?
  • When did the symptom appear the first time, did it appear slowly or suddenly, is it present all the time, how long does it it last after it appears?
  • What triggers the symptom (food, exercise, body position, environmental temperature, etc.) and what relieves it (rest, medication, etc.)?
  • If it is an injury – what happened?

patient and doctor

b) Your other current symptoms (write details of each symptom with the help of “what”, “where” questions as showed above):

c) Time course of your current disease, eventual tests with results and diagnoses given by other doctors, therapies you have tried and their effect.

d) Have you traveled out of your country in last 6 months?

3. Complete Personal Medical History

Childhood and other diseases, injuries, allergies, symptoms, investigations (with results), diagnoses, vaccinations and therapies (and their effect) from birth to present.

4. Current Medications

Current prescribed and over the counter medicines, supplements, physical or other therapy.

5. Life Style

Physical activity, diet, stress, living conditions, smoking, alcohol, street drugs.

6. Family History

1. Does anyone of your close relatives (sisters, brothers, parents, grandparents, children, uncles, aunts) has/had any of the following diseases:

  • Allergies
  • Cancer
  • Diabetes
  • Venous thrombosis or atherosclerosis
  • Angina pectoris (heart related chest pain) or heart attack
  • Stroke
  • Psychiatric disease
  • Other chronic diseases

2. If any of your close relatives has died, at which age and from what cause has he or she died?

Medical History of a Small Child

Children under 5 years of age often can not describe their symptoms clearly, so their parents should speak for them and provide the following information:

NOTE: No official medical history form exists, so your doctor might skip something what you think it is important; in this case just mention all health-related details that left on your mind to your doctor; avoid long stories, though.

After taking your medical history, doctor will likely want to perform a physical examination and sometimes will need to order certain medical investigations before giving you a diagnosis.

Related Articles:

References:

  1. Medical history – a guide for physicians (thelancetstudent.com)

 

About Jan Modric (210 Articles)
Health writer

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