Demo Practice Patient Portal

Sample Forms & Questionnaires

Below are a selection of the forms that we have created and that you may choose to ask patients to complete and submit via the Patient Portal. Many of these forms are variations on the same questions or topics. For patients convenience, it is highly recommended that you select just a few intake questionnaires (up to 5 or so maximum), and be selective about additional forms and questionnaires. Having too many, or highly duplicative, forms available tends to be a source of confusion and frustration for patients.

If you are interested in including one or more of these questionnaires on your patient portal, please check the boxes next to the questionnaires you are interested in. Once you are done, specify any modifications/tweaks in the field at the bottom of this page and then hit submit.

Note: You can open these questionnaires, but submitting them will have no effect.

Medical History Questionnaires

The Health Journey questionnaire covers less medical history details than the others but does includes some social history questions.

Health Journey: Comprehensive Case Review

Medical History Questionnaire - Version 1

Version 1 covers a bit more than Version 2 (such as blood type, GI history, dental history and allergies).

Medical History Questionnaire - Version 2

Version 2 and Version 3 are more specialized than Version 1.

Medical History Questionnaire - Version 3

Medications, Supplements, and Allergies Follow Up

The information in this last form is often captured in the above Medical History Questionnaires. We offer it as a follow-up questionnaire for patients who have changes in any of the areas.

Family History Questionnaires

Family History Questionnaire - Version 1

Family History Questionnaire - Version 2

Family History Questionnaire - Version 3

Social History Questionnaires

Version 1 and Version 2 use different language to cover similar issues, while Version 1 is a little more extensive.

Social History Questionnaire - Version 1

Social History Questionnaire - Version 2

Gender Identity and Sexual Orientation Questionnaire

The information in this last form allows for non-binary gender identification and covers STD history.

Readiness Questionnaires

Readiness Assessment

Symptom Questionnaires

Medical Symptom/Toxicity Questionnaire

Review of Systems

Symptom Review Questionnaire

Specialized Symptom Questionnaires

Allergy Questionnaire

Biotoxin Illness Survey

Digestion Questionnaire

Food and Yeast Allergy Questions

Hormone Questionnaire

Lyme Questionnaires

Version 1 generates a score based on the patient's responses.

Lyme Symptom Questionnaire - Version 1

Lyme Symptom Questionnaire - Version 2

Lyme Symptom Questionnaire - Version 3

Male/Female Questionnaires

Women's Questionnaire

Postmen/Perimenopausal Questionnaire

Men's Questionnaire

Pediatric Questionnaires

The long form covers everything that the short form covers, plus more. The Symptom Review Part 1 covers social/emotional issues while Part 2 focuses on physical symptoms.

Pediatric Medical History (short form)

Pediatric Medical History (long form)

Pediatric Symptom Review 1

Pediatric Symptom Review 2

Diet Questionnaires

Food Survey

3-Day Diet Diary

Other Questionnaires and Assessments

ACE Score

Adrenal Questionnaire

Blood Sugar and Insulin Resistance Questionnaire

Insomnia Questionnaire

Metabolic Assessment Form

Neurotransmitter Assessment Form

Parasite Questionnaire

Thyroid Questionnaire

Consents

Note: You are required by law to have some version of the HIPAA form by the Health Insurance Portability and Accountability Act. For more information and guidelines, visit Model Notices of Privacy Practices.

Authorization to Release Medical Records

Authorization to Release Medical Records (Texas)

General Consent Form

HIPAA Model Notice of Privacy Practices (from HHS.gov)

Medicare Private Contract


 

Request Forms

Please be sure that you have checked every questionnaire that you want added to your Patient Portal. If you require additional forms not seen here, or if you require extensive modification to any of the above questionnaires, please contact support@md-hq.com.
What is your name?
Which Practice are you with?
What is your email address?*

*We will use this to contact you if we have any questions, as well as notify you once the forms have been posted to your Portal.

Specify any minor modifications or tweaks you would like to see. Please be as specific as possible.
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