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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.

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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

☐

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