Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Medical Summary Form Template

Create Comprehensive Health Overviews with Ease

Struggling to compile your patients' health information effectively? This Medical Summary Form Template is crafted for healthcare professionals like you, ensuring a clear and concise overview of a patient's health status. Use it to streamline documentation, improve patient communication, and enhance care coordination, all while adhering to best practices in compliance and accessibility. Explore how this template can simplify your workflow and provide immediate assistance.

Use this Template (FREE) Live Preview
Full name
Date of birth
Sex assigned at birth
Female
Male
Intersex
Prefer not to say
Email
Phone number
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Allergies (include substances and reactions, or write None)
Current medications (name, dose, and frequency)
Medical conditions and diagnoses
Past surgeries or procedures (with dates if known)
Are your immunizations up to date?
Yes
No
Not sure
Primary care provider name
Health insurance provider
Member ID or policy number
Current symptoms or concerns
Height and weight (with units)
Tobacco use
Never
Former
Occasional
Daily
Prefer not to say
Medical devices or implants (e.g., pacemaker, IUD, joint replacement)
Hospitalizations or ER visits in the past 12 months
None
1
2
3 or more
Emergency contact full name
Emergency contact relationship
Spouse/Partner
Parent
Child
Sibling
Friend
Caregiver
Other
Please Specify:
Emergency contact phone
Signature (type your full name)
Date signed
I consent to share this medical summary with the listed healthcare providers
Yes
No
{"name":"Full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name, Date of birth, Sex assigned at birth","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration representing a medical summary form template for FormCreatorAI article

When to use this form

When you need a concise snapshot of a patient's status for handoffs, referrals, or discharge, use this form. It benefits frontline clinicians, care coordinators, and billing teams by putting diagnoses, medications, allergies, and key dates in one place. Use it before a specialist visit, during ED to inpatient transitions, or for telehealth follow-ups to keep everyone aligned. For new patients, pair it with the Hospital patient registration form to capture demographics. Pull background risk factors from the Family medical history form, and summarize current symptoms from the HPI Form. The result: faster decisions, fewer errors, and a clear record that supports continuity of care and insurance documentation.

Must Ask Medical Summary Questions

  1. What is the primary reason for care today?

    This anchors the summary and makes triage and care goals clear. If you need a fuller symptom story, connect it to the HPI Form.

  2. Which diagnoses, procedures, and key dates should be included?

    These details show clinical course and reduce back-and-forth. They also support referrals and billing decisions.

  3. Which medications, doses, and allergies are current?

    Accurate lists prevent interactions and contraindications. You can cross-check entries against the Medical information form.

  4. What recent labs or imaging findings are clinically significant?

    Highlight only results that affect care plans to keep the summary readable. This helps new teams act without digging through charts.

  5. What is the follow-up plan, required monitoring, and patient instructions?

    Clear next steps reduce readmissions and missed care. They also set expectations for the patient and the next provider.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel