Medical History Form Template

What is a medical history form?

A medical history form is the document a patient completes to give a clinician a full picture of their health background: past illnesses and surgeries, family history, social habits that affect health, current medications, and allergies. It is the foundation on which every clinical decision is built. Without it, even the best history of present illness floats free of context.

Most practices use a medical history form on the first visit and review it at intervals. Specialists use a focused version that asks about the systems most relevant to their practice. Hospitals use a longer version that includes preoperative risk and immunization history.

The form is filled out by the patient, a family member, or a caregiver, and then reviewed and signed by the clinician. The clinician's review converts the form from self-report into a clinical document.

What to include on a medical history form

Required sections

• Past medical history with year of diagnosis for chronic conditions
• Surgical history with year and any complications
• Hospitalizations other than surgery and childbirth
• Current medications: name, dose, frequency, reason
• Allergies with reaction type (not just "allergic")
• Family history: parents, siblings, grandparents
• Social history: tobacco, alcohol, recreational drugs, exercise
• Patient signature and date
• Clinician review signature and date

Optional but recommended

• Immunization history with dates
• OB/GYN history including LMP for women of reproductive age
• Mental health history and current treatment
• Sleep, diet, and stress assessment
• Sexual health history
• Preferred pharmacy
• Advance directive status
• Functional status and ADLs (for older adults)
• Travel history (for ID and primary care)

Free medical history form template

Copy the template below, paste it into your word processor, and add your practice letterhead. It is designed to print on two pages.

[PRACTICE NAME]                              MEDICAL HISTORY FORM

Patient: ____________________________   DOB: ____/____/______
Date completed: ____/____/______   Filled out by: [ ] Patient [ ] Other ____

PAST MEDICAL HISTORY (check all that apply, year diagnosed)
[ ] Hypertension ______        [ ] Hyperlipidemia ______
[ ] Diabetes type ___ ______   [ ] Asthma ______        [ ] COPD ______
[ ] Coronary artery disease ______   [ ] Heart failure ______
[ ] Atrial fibrillation ______       [ ] Stroke / TIA ______
[ ] Cancer (type & year) ______      [ ] Kidney disease ______
[ ] Liver disease ______             [ ] Thyroid disease ______
[ ] Anemia ______                    [ ] Seizure disorder ______
[ ] Migraine ______                  [ ] GERD / ulcer ______
[ ] Anxiety ______                   [ ] Depression ______
[ ] Other: __________________________________________________

SURGICAL HISTORY
Procedure                         Year      Complications
______________________________   ______   ______________
______________________________   ______   ______________
______________________________   ______   ______________

HOSPITALIZATIONS (other than surgery / childbirth)
______________________________________________________________

CURRENT MEDICATIONS (include OTC and supplements)
Medication            Dose       Frequency       Reason
______________   ________   ____________   __________________
______________   ________   ____________   __________________
______________   ________   ____________   __________________
______________   ________   ____________   __________________

ALLERGIES
Substance              Reaction (rash, anaphylaxis, GI, etc.)
______________   ____________________________________________
______________   ____________________________________________

IMMUNIZATIONS (most recent dates)
Tdap: ______   Influenza: ______   COVID-19: ______
Pneumococcal: ______   Shingles: ______   HPV: ______
Other: ____________________________________________________

FAMILY HISTORY (relationship, condition, age of onset / death)
Mother: __________________________________________________
Father: __________________________________________________
Siblings: ________________________________________________
Children: ________________________________________________
Grandparents: ____________________________________________

SOCIAL HISTORY
Tobacco: [ ] Never  [ ] Former (quit ____)  [ ] Current ____ packs/day
Alcohol: [ ] None  [ ] Occasional  [ ] ____ drinks/week
Recreational drugs: [ ] None  [ ] ____________________________
Exercise: [ ] <1x  [ ] 1-2x  [ ] 3+x per week
Occupation: __________________  Marital status: __________
Living situation: ____________  Sexual activity: __________

OB/GYN HISTORY (if applicable)
LMP: ____/____/______   Pregnant? [ ] Yes [ ] No [ ] Unsure
G ___ P ___ A ___       Last Pap: ____/____/______
Birth control: ___________________  Last mammogram: ______
Menopausal? [ ] No  [ ] Perimenopausal  [ ] Postmenopausal

MENTAL HEALTH HISTORY
Diagnosed conditions: ______________________________________
Current treatment: __________________________________________
Hospitalizations: __________________________________________
Active thoughts of self-harm or suicide? [ ] No  [ ] Yes
(If yes, please tell us today; staff will support you.)

PREFERRED PHARMACY
Name: ____________________  Phone: __________

ADVANCE DIRECTIVE / LIVING WILL
[ ] On file  [ ] Not on file  [ ] Would like more information

I confirm the above information is accurate to the best of my knowledge.

Patient signature: ________________________  Date: ____________
Reviewed by: _____________________________  Date: ____________

Common mistakes on medical history forms

1. Forgetting LMP for women of reproductive age. Last menstrual period affects medication choices, imaging decisions, and surgical planning. It is the most commonly missed history item in primary care, even though it takes one line.
2. No reaction type column for allergies."Allergic to penicillin" without a reaction type is nearly useless. A rash and anaphylaxis are not the same risk. Always include a reaction column and ask the patient to describe what happened.
3. No preferred pharmacy field. Without a preferred pharmacy on the form, every prescription becomes a phone call. One field saves your team minutes per patient.
4. No advance directive question. Even a yes/no field about whether a living will is on file is important for inpatient and end-of-life care. It is also a starting point for an advance care planning conversation.

Medical history forms for AI scribe users

With PatientNotes, the medical history is captured during the visit conversation. As the patient describes their past surgeries, family history, allergies, and current medications, the scribe extracts and structures the information into the same fields a paper history form would collect. The patient does not have to fill out a separate form, the EHR is populated automatically, and the clinician confirms what the scribe captured before signing the chart.

Frequently asked questions

Related templates