Template

Health History Questionnaire Template

30+

Capture comprehensive patient information with this digital health history questionnaire. Sections include personal details and contacts; current medications and allergies; past medical and surgical history; immunizations; family history; review of systems; women's and men's health; sexual health; and mental health. Use it for new patient intake or periodic updates to support diagnosis, risk assessment, and continuity of care. Fully editable in SafetyCulture to match clinic workflows and record-keeping requirements.

With Mitti you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

With Mitti you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Mitti

Mitti (by SafetyCulture) is the operations system for every site, shift and standard. Trusted by 80,000 organizations in 190 countries, Mitti publishes free checklists, SOP templates, audit checklists and toolbox talk topics that turn paper processes into a digital audit trail. Download one, put it to work on your next inspection or shift, and see why teams keep coming back for more.

Template

Pre-Employment Health Questionnaire and Job Risk Assessment

Use this pre-employment occupational health questionnaire and job risk assessment to evaluate a candidate's fitness for work and identify workplace exposures. Capture medical history, medications, hearing and vision issues, and prior injuries, then assess potential hazards such as noise, vibration, chemicals, dust, UV, shift work, heavy lifting, and extreme temperatures. Refer applicants to an occupational health specialist when risks are identified and schedule ongoing health monitoring as needed. Supports privacy and health information obligations and helps standardize hiring compliance.

by Mark Taylor, from the Community

40+

Get

Template

Medical History Form

A medical history form is filled out to provide a patient’s current medical record and history. It helps medical professionals determine the best possible medical treatment for patients by determining past, and possibly correlated, medical conditions. Maintaining the security of data collected through medical history forms is crucial for healthcare institutions to stay compliant with legal requirements.

by Mitti

70+

Get

Template

Health Questionnaire

A questionnaire to highlight any health concerns

by Scott Bundy, from the Community

50+

Get

Template

Health Questionnaire Template

Use this Health Questionnaire to collect private and confidential health information from employees or candidates. The form captures personal details, emergency contacts, GP information, current medication, recent sickness, vision and hearing, physical capability, and a full medical history including respiratory, cardiac, musculoskeletal, skin, neurological, and metabolic conditions. It supports risk assessment for fitness to work, shift or night work, working at height, manual handling, and exposure to dust or vibration. Include declarations, consent, and notes on reasonable adjustments where required. Customize fields to your policies and keep records organized for occupational health and safety.

by Maria Nolden, from the Community

10+

Get

Template

Contractor Safety Pre-Qualification Questionnaire

This contractor safety pre-qualification questionnaire helps organizations evaluate a contractor’s safety performance and management system before engagement. Assess safety history across the past three years, including first aid cases, medical treatment, lost time, days away, and fatalities. Review regulatory compliance history and the presence of written health and safety policies, programs, and procedures. Verify pre-project hazard analysis, daily toolbox meetings, safety orientations for new hires, and the depth of ongoing training. Collect supporting documentation to standardize vendor screening, improve due diligence, and reduce project risk.

by Advantis Engineering, from the Community

30+

Get

Template

Confidential Employee Health Questionnaire

This confidential employee health questionnaire helps organizations assess fitness for work and identify any adjustments required to support safe employment. It captures personal and emergency contact details, GP surgery information, medical treatments, vision and hearing considerations, physical capabilities, work restrictions such as working at heights or with vibrating tools, and history of relevant conditions. Includes a declaration and guidance on privacy obligations and potential occupational health review.

by Dan Davies, from the Community

10+

Get

Health History Questionnaire Template

About author

You might also like

Pre-Employment Health Questionnaire and Job Risk Assessment

Medical History Form

Health Questionnaire

Health Questionnaire Template

Contractor Safety Pre-Qualification Questionnaire

Confidential Employee Health Questionnaire

You might also like

Pre-Employment Health Questionnaire and Job Risk Assessment

Medical History Form

Health Questionnaire

Health Questionnaire Template

Contractor Safety Pre-Qualification Questionnaire

Confidential Employee Health Questionnaire