Patient Health Questionnaire

Patient Health Questionnaire
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Gender

MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Do you have any chronic medical conditions?

YesNo
If yes, please specify.
Are you currently taking any medications or supplements?

YesNo
If yes, please list them.
Have you ever had surgery?

YesNo
If yes, please provide details.
Do you have any allergies?

YesNo
If yes, please specify.
What is the reason for your visit today?
Please describe your symptoms or concerns.
Do you have a family history of any medical conditions (e.g., heart disease, diabetes, cancer)?

YesNo
If yes, please provide details.
Do you smoke cigarettes?

YesNo
If yes, how many cigarettes per day?
Do you consume alcohol?

YesNo
If yes, how many drinks per week?
Do you exercise regularly?

YesNo
If yes, please describe your exercise routine.
Is there any other information about your health or medical history that you think is important for us to know?
Consent:
By submitting this form, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that this information will be used to assist in my medical evaluation and treatment.
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Date Signed

MonthDayYear
Date
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