New Patient Questionnaire 

The Free New Patient Questionnaire is a comprehensive medical history form designed to be filled out by the health care consumer prior to a visit with a health care provider.   This free medical office form is appropriate for a new patient evaluation or any visit to a health care provider.

The New Patient Questionnaire is a detailed 8-page snapshot of an individual’s current and past medical problems. 

Information included in the Questionnaire

  • Allergies
  • Medications
  • Surgeries
  • Past Medical History
  • Family Medical History
  • Review of systems
  • Social History
  • Religious and cultural beliefs
  • Travel history
  • Occupational history
  • Carcinogen exposure history
  • Behavioral risk factors
  



Check out our FREE Medicare DRG modifier worksheet.


MedicalTemplates are in the Adobe PDF format, which requires the free Adobe Reader.  With Adobe Reader, these templates can be printed as many times as needed on paper meeting your specifications or the specifications of any clinic, hospital, or other health care facility.

Get Adobe Reader