Chronic Illness Health Questionnaire
Please complete this questionnaire to share your chronic illness history, current symptoms, treatments, and follow-up needs.
Patient Overview
Full Name
*
First Name
Middle Name
Last Name
Age
*
Preferred Contact Method
*
Phone
Email
Text Message
Chronic Condition Details
Primary chronic condition(s) or diagnosis
*
Asthma
Diabetes
Hypertension
Chronic pain
COPD
Arthritis
Depression
Anxiety
Heart disease
Kidney disease
Other
Duration since diagnosis
*
Currently managed by a healthcare professional?
*
Yes
No
Symptoms and Management
Current symptoms or concerns
*
Current medications or treatments
*
Known triggers, limitations, or recent changes
Care Coordination
Primary Care Provider or Specialist Name
Best Follow-Up Contact Details for Care Coordination
Additional Notes or Questions
Submit
Should be Empty: