Templates Health & Wellness Medical Medical History Form Template

Medical History Form Template

Use This Template
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Patient Name


Doctor Name
Doctor's Healthcare Facility Address


Medical History Terms & Conditions

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.
Clear Signature

Use the medical history form template to provide essential medical details to healthcare providers. The health facility needs accurate and detailed historical medical information to treat people safely.

Check out the medical history form below:

What Should Be on a Medical History Form?

The form should include:

  • Patient contact details
  • Patient’s healthcare professional’s information
  • An extensive questionnaire about the patient’s medical background
  • The patient’s signature acknowledging the terms and use of providing this information

What’s in Our Medical History Form?

In our medical history form template, we’ve asked if patients have any current medical conditions, if they’re currently taking medication, to list any allergies, congenital disorders, and anything that hasn’t been mentioned.

With this template, you can quickly and easily edit it. Take your medical history questionnaire to the next level and ask the patient their weight, alcohol and tobacco consumption, and if they have any hearing, sight, or mobility issues.

You can then add a ‘Have you ever had’ section. This is where you can retrieve comprehensive detail. Ask if they have or had asthma, angina, bone or joint disease, liver disease, addiction, and more!