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Medical Review Form Template

Streamline Your Patient Assessments with This Template

Trying to gather crucial health insights can feel overwhelming without the right tools. This Medical Review Form Template helps healthcare professionals effectively collect patient information and assess health conditions. By using this template, you can effortlessly gather details on daily activities, sexual health, and symptom reviews, ensuring a thorough understanding of your patients' needs. Plus, it's designed with WCAG-aligned labels for better accessibility. Experience the ease of using this template today!

Use this Template (FREE) Live Preview
Full name
Date of birth
Email
Phone
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
What would you like us to review or help with?
How urgent is this?
Not urgent
Within 1 week
Within 3 days
Within 24 hours
If previously evaluated, what was done or advised? (optional)
Have you consulted a clinician about this already?
Yes
No
Do you have any ongoing conditions?
Please Specify:
Current medications and doses (include over-the-counter and supplements)
Do you have any medication or food allergies?
Yes
No
List allergies and reactions (optional)
Are you currently pregnant or planning pregnancy?
Yes
No
Not applicable
Prefer not to say
Do you use tobacco or nicotine?
Never
Former
Occasional
Daily
How often do you drink alcohol?
Never
Rarely
Sometimes
Often
Always
In the last 30 days, have you traveled internationally or had close contact with a contagious illness?
Yes
No
Primary care provider or clinic (optional)
Preferred contact method
Email
Phone call
Text message
Any of the above
Best times to contact you (local time)
Insurance provider and member ID (optional)
Pharmacy of choice (name and location) (optional)
Do you have health insurance?
Yes
No
I consent to a non-emergency medical review and to be contacted about this request.
Yes
No
Typed full name (serves as signature)
Date
I understand this form is not for emergencies and I will call local emergency services for urgent symptoms.
Yes
No
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Paper art illustration depicting a medical review form with design elements related to healthcare and documentation.

When to use this form

Use this form when you need a clear snapshot of a patient's current health before triage, treatment, or referral. It helps clinics, telehealth teams, and workplace health programs gather symptoms, history, meds, and risks in minutes. Use it for new patient intake, post-illness check-ins, and pre-procedure reviews. If you are screening a population, pair it with a Health screening form. For deeper history or ongoing care plans, add a Medical questionnaire form. Pre-surgical clinics can adapt it alongside a Pre-op clearance form. You can also turn it into a review of symptoms template to standardize visits and reduce back-and-forth calls. The result: faster routing, safer decisions, and fewer documentation gaps.

Must Ask Medical Review Questions

  1. What symptoms are you experiencing today, and when did they start?

    Onset and progression help you assess severity and urgency. Clear timing supports triage and guides next steps, such as watchful waiting versus immediate evaluation.

  2. Do you have any chronic conditions, past surgeries, or hospitalizations we should know about?

    History shapes risk and rules in or out likely causes. It also helps you avoid tests and treatments that could be unsafe or unnecessary.

  3. Which medications and supplements are you taking, and do you have any drug or food allergies?

    This prevents dangerous interactions and adverse reactions. It improves prescribing accuracy and reduces delays in care.

  4. Have you had recent exposure to tuberculosis or a positive TB test?

    Infectious risk changes isolation, testing, and follow-up. If needed, you can route patients to a dedicated TB Screening form for detailed assessment.

  5. How is your condition affecting your job duties or daily activities?

    Functional impact guides work restrictions, accommodations, and return timelines. When appropriate, coordinate with a Return to work form to document clearance and next steps.

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