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HPI Form Template

Streamline Patient Assessments with Our HPI Template

Collecting detailed patient histories can be time-consuming and complex. Our HPI form template is designed for medical professionals seeking to gather clear and concise information on patient illnesses, ensuring accurate diagnoses and effective treatment plans. With this template, you can streamline data collection, improve communication with patients, and enhance your documentation process, all while maintaining compliance with medical standards. Experience the benefits of using our user-friendly HPI form template today.

Full name
Date of birth
Phone number
Email address
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
What is your main concern today?
When did this problem start?
How did it start?
Suddenly
Gradually
After an injury
After an illness
After a medical procedure
Not sure
Since it started, this problem is:
Improving
Worsening
Unchanged
Not sure
Where is the problem located?
Does it spread to other areas?
Yes
No
How severe is it at its worst?
None
Mild
Moderate
Severe
Very severe
Which qualities describe it?
Please Specify:
What makes it worse?
Which associated symptoms are you experiencing?
Have you seen a clinician for this problem?
Yes
No
What treatments have you tried for this problem?
Please Specify:
If you tried treatment, how much did it help?
No help
Slight help
Moderate help
Significant help
Resolved
Not applicable
List your current medications (name and dose if known)
List any medication allergies and reactions
Do you have any of the following conditions?
Please Specify:
Tobacco or nicotine use
Never
Former
Current some days
Current every day
Vapes only
Prefer not to say
Alcohol use
Never
Monthly or less
2-4 times a month
2-3 times a week
4+ times a week
Prefer not to say
Is there any chance you are pregnant?
Yes
No
Not applicable
Prefer not to say
Do you have any of the following right now?
What is your primary goal for this visit?
How much does this problem affect your daily activities?
Not at all
A little
Some
A lot
Unable to do usual activities
Patient or guardian typed name
Date
I confirm the information provided is accurate to the best of my knowledge.
True
False
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Paper art illustration related to HPI Form Template and FormCreatorAI in a creative layout.

When to use this form

Use this template when you need a clear, structured history of the current symptom before or during a visit. It helps primary care, urgent care, telehealth, and rehab teams capture onset, location, quality, severity, and modifiers in minutes. Use it at check-in to speed triage, during a virtual visit to guide questions, or after an injury to track progress. Pair it with the Patient encounter form to document assessment and plan, and with the Medical history form to pull chronic conditions and medications into context. For wellness or multi-condition reviews, the Health profile form form helps round out risk factors. Teams get consistent notes, fewer gaps, and faster decisions.

Must Ask HPI Questions

  1. When did the problem start, and how has it changed since then?

    Timeline anchors the episode and flags urgency or chronicity. It helps you spot patterns like sudden onset versus gradual build, which guides testing and triage.

  2. Where is the symptom located, and does it radiate anywhere?

    Location and radiation help narrow the source and rule in or out referred pain. Clear mapping supports accurate exams and imaging orders.

  3. How would you describe the symptom quality and severity (include a 0-10 rating)?

    Quality words like sharp, burning, or pressure point to likely causes. A numeric scale lets you track response to treatment over time.

  4. What makes it better or worse, including activities, positions, and tried medications?

    Modifiers reveal biomechanics, triggers, and effective self-care. For functional issues, your notes can feed into the Physical therapist evaluation form.

  5. What related symptoms are present, and how does this affect daily activities or work?

    Associated signs and functional impact uncover red flags and severity. This context supports safer decisions and prioritizes next steps.

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