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Medical History Form

Take a full history before the first appointment, so clinical time goes on the consultation rather than on filling in a paper form.

Medical History Form

Take a full history before the first appointment, so clinical time goes on the consultation rather than on filling in a paper form.

Home address

Home address

Current health

Include the dose if you know it.

History

Lifestyle

Sign above

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Use this template

Opens in the builder. Nothing is saved until you edit it.

Fields
14 questions
Theme
Default, switchable in the preview
Updated
11 August 2026

Categories

  • Healthcare
  • Healthcare Forms
  • Intake Forms
  • Patient Forms

Ideal for

  • Clinics
  • GP surgeries
  • Physiotherapists
  • Private practice

Best used in

  • New patient registration
  • Pre appointment intake
  • Annual reviews

About this template

A history taken on paper in the waiting room is rushed, hard to read, and has to be typed up by somebody afterwards. Sent as a link before the appointment, it gets filled in at home where the patient can check the name of the medication they take, and it arrives legible and already searchable.

The conditions checklist is followed by a single open field for dates and treatment rather than a separate question per condition. That keeps the form short for the majority who tick one box or none, while still capturing the detail that matters for anyone with a longer history. Allergies gets its own field because it is the one answer clinical staff need to find in under a second.

Add a next of kin section if you see patients under sedation, and add a rule so the smoking follow up only appears for the answers that need it. If you handle records under HIPAA or UK GDPR, review retention before you collect anything.

Templates are a starting point, not legal or professional advice. Where a form carries consent, medical, or contractual wording, have somebody qualified review it against the rules that apply to you before you publish.

Fields in this template

  • Full name*Short text
  • Date of birth*Date
  • Contact number*Phone
  • Email addressEmail
  • Home addressAddress
  • Have you ever been diagnosed with any of the following?Multiple choice
  • Please give dates and treatment for anything you tickedLong text
  • Medication you take regularlyLong text
  • AllergiesLong text
  • Past operations and hospital staysLong text
  • Relevant family historyLong text
  • Do you smoke?Single choice
  • Alcohol in a typical weekDropdown
  • Signature*Signature

Every field can be renamed, reordered, made optional, or removed once the template is open in the builder.

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