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Patient Intake · Popular

Streamline New Patient Intake with One Easy Form

Gather complete medical history, current medications, surgical background, and emergency contacts from new patients before their first visit.

Use This Template Free Preview

Umber theme

formbuilder.ai/f/primary-care-physician-new-patient-medical-history-health-questionnaire-intake-form

Primary Care Physician New Patient Medical History & Health Questionnaire Intake Form

Patient Full Name

· · ·

Date of Birth

· · ·

Sex

Submit

The Primary Care Physician New Patient Medical History & Health Questionnaire Intake Form is designed to help medical practices collect comprehensive patient information before the first appointment. It covers personal details, emergency contacts, past diagnoses, surgical history, family medical history, and current medications—all in one organized digital form.

This template is ideal for primary care offices, family medicine practices, and general practitioners who need a reliable, HIPAA-conscious way to gather health data efficiently. By digitizing the intake process, you reduce paperwork, minimize data entry errors, and give patients the convenience of completing their history ahead of time.

With a customizable structure, you can tailor the form to match your practice's specific screening needs. Save staff time, improve data accuracy, and create a smoother onboarding experience for every new patient from day one.

4 Pages

27 Questions

~9min To complete

Free No credit card needed

Field types Long Text ×6 Single Choice ×4 Yes / No ×3 Full Name ×2 Date ×2 Phone ×2 Multiple Choice ×2 Email Address Short Text Star Rating termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Personal Information 9 questions

Patient Information

1 Patient Full Name * Full Name

2 Date of Birth * Date

3 Sex * Single Choice

4 Email Address * Email

5 Phone Number * Phone

6 Home Address * Address

Emergency Contact

7 Emergency Contact Name * Full Name

8 Emergency Contact Phone Number * Phone

9 Relationship to Patient * Short Text

Page 2 Medical History 5 questions

Past Medical History

1 Have you ever been diagnosed with any of the following conditions? * Multiple Choice

2 If applicable, please provide details on any conditions selected above (diagnosis date, current status, etc.) Long Text

Surgical History

3 Have you ever had any surgeries? * Yes / No

4 If yes, please list surgeries with approximate dates Long Text

Family Medical History

5 Do any of your immediate family members (parents, siblings) have a history of the following? * Multiple Choice

Page 3 Medications, Allergies & Lifestyle 7 questions

Current Medications

1 Are you currently taking any medications, vitamins, or supplements? * Yes / No

2 Please list all current medications, dosages, and frequency Long Text

Allergies

3 Do you have any known allergies (medications, food, environmental)? * Yes / No

4 Please list all allergies and describe the reaction for each Long Text

Lifestyle & Social History

5 Do you currently use tobacco products? * Single Choice

6 Do you consume alcohol? * Single Choice

7 How often do you exercise? * Single Choice

Page 4 Current Health & Consent 6 questions

Reason for Visit

1 What is the primary reason for your visit today? * Long Text

2 How would you rate your overall health? * Star Rating

Additional Information

3 Is there anything else you would like your physician to know? Long Text

Consent & Acknowledgement

4 I certify that the information provided is accurate and complete to the best of my knowledge. I authorize the use of this information for my medical care and understand that my records will be kept confidential in accordance with HIPAA regulations. * termsandconditions

5 Patient Signature * Signature

6 Date Signed * Date

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.