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HIPAA Medical History Form Template

Streamline Patient Care with Our HIPAA-Compliant Template

Collecting accurate medical history can be challenging, especially when patient privacy is a concern. Our HIPAA Medical History Form template is designed to help healthcare providers efficiently gather essential patient information, ensuring compliance and accuracy. You can streamline patient intake, easily track symptoms and medications, enhance your practice's efficiency, and maintain detailed records that comply with HIPAA regulations. Start using this user-friendly template today and improve your healthcare management process.

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Full legal name
Date of birth
Sex assigned at birth
Female
Male
Intersex
Prefer not to say
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email address
Mobile phone number
Street address
City, state/province, and ZIP/postal code
Preferred language
English
Spanish
Chinese
Hindi
Arabic
French
Prefer not to say
Other
Please Specify:
Preferred contact method
Phone call
SMS text message
Email
Postal mail
No preference
May we leave voicemail messages at the number provided?
Yes
No
Emergency contact name
Emergency contact relationship to you
Spouse/Partner
Parent
Child
Sibling
Friend
Caregiver
Other
Please Specify:
Emergency contact phone
Primary care provider name
Preferred pharmacy (name and location)
You may share relevant health information with my emergency contact
Yes
No
Insurance carrier
Member ID / Policy number
Insurance status
Insured
Self-pay
Workers compensation
Auto claim
Other
Please Specify:
Primary reason for visit or current concerns
Approximate symptom onset date
If applicable, list prior evaluation or treatment for this concern
Have you had this issue before?
Yes
No
Do you have any medication or food allergies?
Yes
No
List allergies and reactions
List medication/supplement names with dose and frequency
Are you currently taking any medications, including over-the-counter medicines or supplements?
Yes
No
Other medical conditions (if any)
Have you ever been diagnosed with any of the following?
Please Specify:
List surgeries or hospitalizations with dates (if known)
Have you had any surgeries or hospitalizations?
Yes
No
Family history details (condition and relative)
Do any close relatives have a history of the following?
Please Specify:
Tobacco or nicotine use
Never
Former
Current some days
Current daily
Vaping only
Prefer not to say
Alcohol use
Never
Monthly or less
2-4 times per month
2-3 times per week
4+ times per week
Prefer not to say
Recreational drug use
Never
Past use
Current use
Prefer not to say
Exercise frequency
Never
Rarely
Sometimes
Often
Always
In the past 2 weeks, have you experienced any of the following?
Please Specify:
Date of last menstrual period (LMP)
Current pregnancy or breastfeeding status
Pregnant
Breastfeeding
Trying to conceive
Not pregnant
Not applicable
Prefer not to say
Are your routine immunizations up to date?
Yes
No
Not sure
COVID-19 vaccination status
Not vaccinated
Partially vaccinated
Fully vaccinated
Fully vaccinated with booster(s)
Prefer not to say
I acknowledge receipt of the Notice of Privacy Practices (HIPAA).
Yes
No
I authorize the release of medical information for treatment, payment, and healthcare operations.
Yes
No
I consent to receive appointment reminders by SMS text.
Yes
No
Patient signature (print full name)
Signature date
I certify that the information provided is accurate to the best of my knowledge.
Yes
No
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Paper art illustration depicting a HIPAA medical history form template.

When to use this form

Use this secure form when you need a complete record before treating a new patient, during annual updates, or before procedures. It suits primary care, telehealth, specialty clinics, and small practices that share records across teams. Patients fill it at home or on a tablet to cut lobby time and reduce transcription errors. You get allergies, medications, surgeries, conditions, family history, and consents in one place, ready for your EHR. For a shorter intake, start with the Medical history form. If you screen for mood or stress, add the Patient health questionnaire form. Chiropractors can combine this with the Chiropractic intake form to capture pain history and functional limits.

Must Ask HIPAA Medical History Questions

  1. What medications and supplements are you currently taking, including dose and frequency?

    Knowing exact meds helps prevent dangerous interactions and dosing errors. It also speeds medication reconciliation and informs safe prescribing.

  2. Do you have any allergies or adverse reactions to medications, vaccines, latex, foods, or environmental triggers?

    Documented allergies and reactions let your team avoid exposures that could cause harm. Specific reactions (for example, rash vs. anaphylaxis) guide risk and treatment choices.

  3. What major diagnoses, chronic conditions, and past surgeries or hospitalizations should we know about, including dates and complications?

    This history reveals risks, baseline status, and likely follow-up needs. Dates and outcomes help your clinician see patterns and plan care.

  4. Do you have a family history of heart disease, stroke, cancer, diabetes, or inherited conditions?

    Family history shapes screening schedules and preventive counseling. It may prompt earlier testing or referrals for genetic evaluation.

  5. Do you consent to our use and sharing of your health information for treatment, payment, and healthcare operations, and how may we contact you with results or reminders?

    Clear consent and communication preferences support HIPAA compliance and protect your privacy. It also reduces delays in care by allowing timely coordination with your care team.

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