Medical History Form Template
Free printable medical history form templates for your practice. Comprehensive questionnaires covering medications, allergies, family history, and more.
What is a Medical History Form?
A medical history form (also called a health history questionnaire) is a comprehensive document that captures a patient's past and present health information. It's one of the most important documents in healthcare, providing clinicians with critical information needed to make safe, informed treatment decisions.
These forms are typically completed by new patients before their first appointment and updated periodically thereafter. A thorough medical history helps identify potential drug interactions, uncover hereditary health risks, and establish baseline health information.
Why Medical History Matters
70%
of diagnoses rely on patient history alone
30%
of adverse drug events are preventable with history review
50%
of family history reveals hereditary disease risk
Essential Medical History Form Sections
A comprehensive medical history form should cover these six key areas to provide a complete picture of patient health.
Personal Information
- Full legal name
- Date of birth
- Social Security Number (last 4)
- Address and phone number
- Emergency contact
- Preferred pharmacy
Current Medications
- Prescription medications
- Over-the-counter drugs
- Vitamins and supplements
- Herbal remedies
- Dosages and frequency
- Prescribing physician
Allergies
- Medication allergies
- Food allergies
- Environmental allergies
- Latex allergies
- Reaction type (mild/severe)
- Anaphylaxis history
Past Medical History
- Chronic conditions
- Previous hospitalizations
- Surgical history
- Major illnesses
- Injuries and accidents
- Mental health conditions
Family History
- Heart disease
- Cancer (types)
- Diabetes
- High blood pressure
- Mental health disorders
- Genetic conditions
Social History
- Tobacco use
- Alcohol consumption
- Drug use history
- Exercise habits
- Occupation
- Living situation
Medical Conditions Checklist
Include a comprehensive conditions checklist in your medical history form. Here are the most common categories and conditions to include.
Cardiovascular
Respiratory
Endocrine
Gastrointestinal
Mental Health
Other
Sample Medical History Form
PATIENT MEDICAL HISTORY FORM
Please complete all sections to the best of your ability
1Patient Information
2Current Medications
3Allergies
This is a preview. Download the complete template below.
Download Free Medical History Templates
Print-ready HTML templates. Open in your browser and print to PDF.
Full questionnaire with all sections
Demographics, insurance, basic history
Open templates in browser, then use File > Print > Save as PDF to download.
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Best Practices for Medical History Forms
Do
- • Use clear, simple language patients can understand
- • Include checkbox options for common conditions
- • Provide adequate space for written responses
- • Request signature and date for verification
- • Make forms available in multiple languages
- • Review and update forms annually
Don't
- • Use medical jargon patients won't understand
- • Make forms longer than necessary
- • Ask for unnecessary personal information
- • Forget to include allergy severity levels
- • Skip family history for hereditary conditions
- • Ignore accessibility needs (font size, contrast)
Frequently Asked Questions
What should be included in a medical history form?
A complete medical history form should include: personal information (name, DOB, contact details), current medications, allergies, past medical conditions, surgical history, family health history, social history (smoking, alcohol, exercise), current symptoms, immunization records, and emergency contact information.
How often should medical history be updated?
Medical history should be reviewed and updated at least annually for healthy adults, or more frequently for patients with chronic conditions or significant health changes. Many practices update the form at each visit by asking patients to review and confirm their information.
Can patients fill out medical history forms electronically?
Yes, electronic medical history forms are increasingly common and preferred. Digital forms can be completed before the appointment, integrate directly with EHR systems, and reduce data entry errors. Services like PatientNotes offer digital intake that flows directly into clinical documentation.
What is the difference between medical history and health history?
The terms are often used interchangeably. Medical history typically refers to past illnesses, surgeries, and treatments. Health history is a broader term that may include lifestyle factors, family history, and social determinants of health. Both are essential for comprehensive patient care.
How long should medical history records be kept?
Medical records should be kept for at least 7-10 years after the last patient encounter for adults, and until age 21 (or longer) for pediatric patients. Requirements vary by state and specialty. HIPAA requires records be retained for 6 years from creation or last effective date.
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