MAKE YOUR FREE Medical History Form
What is a Medical History Form?
A Medical History Form is a document that outlines a patient's health. A typical medical history form identifies any medical conditions, diagnoses, and health patterns of a patient. A medical history form is usually filled out when a new patient is admitted to a hospital or doctor's office for treatment and is used to provide the attending health care provider with a patient's medical history.
When to use a Medical History Form:
- You would like to create a file for a new patient.
- You would like to have a record of past diagnoses.
- You would like to enable contract tracing.
Sample Medical History Form
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Personal Information
Full Name:
Birth Date:
What is the reason for your visit?
__________________________________________________________________________
| Do you have any allergies? | Yes | No |
If yes, please list:
__________________________________________________________________________
Past Medical History
Check the boxes if you currently experience or have experienced any of the following:
☐ Arthritis
☐ Cancer
☐ Depression
☐ Diabetes
☐ Epilepsy/Seizures
☐ Heart Problems
☐ Heart Surgery
☐ High Blood Pressure
☐ Liver Disease
☐ Kidney Disease
☐ Stroke
☐ Thyroid Disease
☐
