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Medical Information Form Template

Streamline patient data collection with our medical information form

Gathering accurate health information can be challenging, especially when time is of the essence. This medical information form template is designed to help healthcare providers collect vital patient data, ensuring you have the information you need for effective treatment. Benefit from improved patient intake processes, enhanced data accuracy, compliance with regulations, and the ability to customize questions to suit your practice-all while providing a user-friendly experience for your clients. Explore the live template to see how it can streamline your workflows.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
If you prefer to self-describe your gender, please enter it (optional)
Pronouns (optional)
Email address
Mobile phone
Home address
Preferred contact method
Email
Phone call
Text message
No preference
Emergency contact full name
Emergency contact phone
Relationship to you
Spouse/Partner
Parent
Child
Sibling
Friend
Caregiver
Other
Please Specify:
Do you have health insurance?
Yes
No
Prefer not to say
Primary insurance provider (if applicable)
Member ID (if applicable)
Policyholder name (if different)
Policyholder date of birth (if applicable)
Do you consent to electronic verification of your insurance for eligibility and benefits?
Yes
No
Primary care provider name
Provider clinic or practice name
Provider phone
Preferred pharmacy name and location
Pharmacy phone
Ongoing or chronic conditions (select all that apply)
Please Specify:
Past surgeries or procedures
None
Yes
If you had surgeries or procedures, please list names and dates (or write None)
Family medical history among immediate family (select all that apply)
Please Specify:
Are you currently taking any medications or supplements?
No
Yes
List current medications and supplements with dose and frequency (or write None)
Allergies (select all that apply)
No known allergies
Medications
Foods
Latex
Environmental (e.g., pollen)
Insect stings
Other
Please Specify:
List specific allergens and reactions (or write None)
Date of last tetanus shot (if known)
Vaccination status
Up to date
Partially up to date
Not up to date
Not sure
Tobacco or nicotine use
Never
Former
Current some days
Current every day
Vaping 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
Recreational drug use in the past 12 months
No
Yes
Prefer not to say
Exercise frequency
Never
Rarely
Sometimes
Often
Always
Is there any chance you are currently pregnant?
Yes
No
Not applicable
Prefer not to say
Accessibility or accommodation needs (select all that apply)
None
Mobility support
Vision support
Hearing support
Cognitive support
Communication support
Prefer not to say
Other
Please Specify:
Reason for visit or main concerns
When did this issue begin?
Severity of symptoms today
None
Mild
Moderate
Severe
Not applicable
Pain location (if any)
If yes, where and when (optional)
Have you had any recent tests or imaging related to this concern?
No
Yes
I consent to evaluation and treatment by the provider
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I acknowledge the privacy notice and how my information may be used for treatment, payment, and operations
Strongly disagree
Disagree
Neither
Agree
Strongly agree
May we leave detailed voicemail about your care at your provided phone number?
Yes
No
Type your full name to serve as your signature
Date of signature
May we share relevant information with other providers directly involved in your care?
Yes
No
Not sure
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paper art illustration related to medical information form template and FormCreatorAI

When to use this form

Use this template when you need a clear snapshot of a patient's health details before care, travel, or activities. Clinics can attach it to the new patient intake to speed triage and reduce back-and-forth; pair it with the New patient registration form. Schools, camps, and sports programs can collect meds, allergies, and emergency contacts ahead of season start. Employers and telehealth teams can review risks and current treatments prior to visits, and update records after checkups with the Health examination form. If you also track long-term diagnoses and treatments, link this form to a fuller Medical history form so staff see the right context and make faster, safer decisions.

Must Ask Medical Information Questions

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

    This helps prevent harmful interactions and guides safe prescribing. Include prescription, over-the-counter, and supplements so your record stays accurate.

  2. Do you have any allergies to medicines, foods, or materials, and what reactions do you have?

    Reaction details help gauge severity and select safe alternatives. This protects you during procedures, diagnostics, and prescribing.

  3. What past or ongoing conditions have you been diagnosed with?

    Your conditions give context for symptoms, risks, and treatment choices. For a concise overview that staff can scan quickly, align responses with a Medical summary form.

  4. Have you had any surgeries, hospitalizations, or major procedures, and when?

    Dates and outcomes reveal complications, anesthesia risk, and follow-up needs. This history also informs imaging or lab choices and avoids duplicate tests.

  5. Who is your primary care physician and preferred pharmacy, with contact details?

    Contact info enables fast care coordination, refills, and record requests. It also helps verify medications and route prescriptions without delays.

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