Patient Medical History Form

Streamline patient intake with this comprehensive medical history form. The user-friendly template captures vital health data, from allergies to surgeries, ensuring thorough, safe, and effective patient care for your clinic or hospital.

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Patient Medical History Form Template

Ensure safe thorough, and effective patient care with this complete medical history form

Patient Medical History Form

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Patient Medical History Form (#214)

Basic Info & Reason for Visit
Medical History
Medications & Allergies
Family History & Lifestyle

Patient Medical History Form Banner The information on this form helps your healthcare provider understand your health status and provide the best care. All your answers are confidential. Please answer each question as accurately and completely as you can.

Date

Patient Information

First Name

Last Name

Age

Address

Phone/Mobile

Gender Assigned at Birth

Male

Female

Intersex/Other

Primary Care Physician (PCP)

Emergency Contact Name

Relationship to Patient

Emergency Contact's Phone

Reason for Today's Visit

Primary Concern(s) Today

When Did It Start?

What Makes It Better/Worse?

About this template...

Features of this Template

Allows you to collect the patient’s and emergency contact’s details.
Collects patient’s history, including medical conditions & surgeries.⁣
Collects patient’s allergic reaction to different medications/allergens.
Captures vital information on the patient’s current medication.
Collects patient’s family members’ medical history.
Collects patient’s lifestyle information like diet, alcohol intake, etc.
The multi-step layout of the template makes it easy to fill.

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Input Fields Used in this Template

Name Fields, Email, Simple Text, Text Area, Address Fields, Radio Field, Checkbox, Time & Date, Custom HTML, One Column Container, Two Column Container, Phone/Mobile, Form Step, Repeat Field, Repeater Container Field

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Features of this Template

Allows you to collect the patient’s and emergency contact’s details.
Collects patient’s history, including medical conditions & surgeries.⁣
Collects patient’s allergic reaction to different medications/allergens.
Captures vital information on the patient’s current medication.
Collects patient’s family members’ medical history.
Collects patient’s lifestyle information like diet, alcohol intake, etc.
The multi-step layout of the template makes it easy to fill.

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