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Medical History Form Template

Streamline Patient Data Collection with This Template

Filling out a medical history form can be daunting for patients, but it's crucial for their care. This template helps healthcare providers efficiently gather important information, ensuring a comprehensive view of each patient's health. Benefit from clear organization, easy integration into your practice, and WCAG-aligned labels for accessibility. With this medical history form template, you can minimize errors, save time, and facilitate accurate diagnoses. Explore the live template to see its benefits in action.

Use this Template (FREE) Live Preview
Full name
Date of birth
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
If you selected 'Prefer to self-describe', please specify
Phone number
Email address
Home address
Preferred language
Preferred contact method
Phone
Email
Text message
No preference
Emergency contact full name
Emergency contact phone
Relationship to you
Spouse/Partner
Parent
Child
Sibling
Relative
Friend
Caregiver
Other
Please Specify:
Insurance provider
Member or policy ID
Primary care provider name
Preferred pharmacy
Do you have health insurance?
Yes
No
Please select any current or past conditions you have been diagnosed with
Please Specify:
If 'Other', please list other conditions
Have you ever had surgery?
Yes
No
If yes, please list surgeries and dates
If yes, please describe the reason and dates of hospitalization
Have you been hospitalized in the last 5 years?
Yes
No
Are you currently taking any prescription medications, over-the-counter medicines, or supplements?
Yes
No
Please list medication/supplement names, doses, and frequency
Do you have any medication allergies?
Yes
No
List medication allergies and reactions
List other allergies and reactions
Do you have any food or environmental allergies?
Yes
No
Which symptoms are you experiencing now?
Please Specify:
Please describe your main concern today
If yes, please describe your accessibility needs
Do you have any mobility or accessibility needs we should be aware of?
Yes
No
Please list relatives affected and their conditions
Has anyone in your immediate family been diagnosed with any of the following?
Please Specify:
Tobacco use
Never
Former
Occasionally
Daily
Prefer not to say
Alcohol use frequency
Never
Rarely
Sometimes
Often
Always
Recreational drug use
Yes
No
Prefer not to say
How often do you exercise at least 30 minutes?
Never
Rarely
Sometimes
Often
Always
Occupation
Typical diet
Omnivore
Vegetarian
Vegan
Pescatarian
Low carb
Low salt
Gluten-free
Prefer not to say
Other
Please Specify:
Are your vaccinations up to date?
Yes
No
Not sure
Date of last tetanus shot
Did you receive a flu shot this season?
Yes
No
Not sure
Which screenings have you had?
Colonoscopy
Mammogram
Pap smear
PSA
Bone density
Skin cancer check
None
Not applicable
Date of last menstrual period
Please select any that apply
Pregnant
Planning pregnancy
Breastfeeding
Using hormonal contraception
Using IUD/implant
Post-menopausal
None
Not applicable
I consent to evaluation and treatment by the provider
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I authorize release of relevant medical information to my insurer for claims processing
Yes
No
Type your full name as your signature
Date signed
I acknowledge I have received or been offered the Notice of Privacy Practices
Yes
No
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Paper art illustration related to medical history form template for FormCreatorAI article

When to use this form

Use this form whenever you onboard a new patient, prepare for a procedure, or manage chronic care. Collect medications, allergies, surgeries, and family risks before an appointment so you can triage faster and chart accurately. It works well for primary care, urgent care, and telehealth intakes. Pair it with the Medical intake form to capture contact, insurance, and consent in one flow. For women's health visits, direct OB-specific questions to the Ob gyn patient history form. Clinics also use this form ahead of annual physicals and sports clearances to flag issues early and reduce back-and-forth. The result: shorter visits, fewer errors, and safer prescribing.

Must Ask Medical History Questions

  1. What medications, vitamins, or supplements are you currently taking, including doses and schedules?

    This helps you avoid dangerous interactions and duplicate therapies. Clear details support accurate prescribing and safe refills.

  2. Do you have any allergies or past reactions to medications, foods, or latex?

    Knowing triggers prevents adverse events and guides safer alternatives. It also shapes vaccine choices and procedural prep.

  3. What surgeries, hospitalizations, or major illnesses have you had, and when?

    Your timeline gives context for symptoms and risk. It helps you target exams, testing, and follow-up.

  4. Which chronic conditions have you been diagnosed with, and how are they currently managed?

    Active problems guide care plans and screening. Current control and treatments inform goals and medication choices.

  5. What conditions run in your family (parents, siblings, grandparents)?

    Family patterns reveal genetic risk and need for earlier screening. They also guide lifestyle counseling and prevention.

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