Telemedicine Patient History Questionnaire
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Contact Number
Email Address
Address
Medical History
Chief Complaint / Reason for Consultation
Current Symptoms
Onset and Duration
Past Medical History
Current Medications
Allergies
Surgical History
Family Medical History
Social History (e.g., smoking, alcohol, occupation)
Other Relevant Information