The types of questions that appear on a patient application form vary according to the nature of the form, though many ask for the patient's name, address, contact information and a general description of her health history. Some forms may inquire about her financial background, past drug usage or if she has any health insurance.
Most patient application forms begin by collecting the personal information of the patient, in order to create a file for her within the office and compare her data against other records. Some medical programs require patients to submit an application form in order to participate, such as with a clinical trial or to receive treatment with medical marijuana. These application forms may contain numerous questions regarding the current health of the patient, including the presence of any diseases or disabilities and their subsequent symptoms. It is also common for these forms to ask about past and current drug, alcohol and tobacco usage, including frequency and severity.
Many patient application forms also include questions about the patient's family medical history, usually focusing on her immediate relatives. These questions look for a history of major ailments such as cancer, heart disease, diabetes or mental illness. Depending on the nature of the program or treatment to which she is applying, the form may also ask questions regarding her health insurance coverage. It is also possible for the form to feature questions about her lifestyle, such as hobbies or work life.