Medical History Form

Medical History Form

What Is a Medical History Form?

A Medical History Form is a document that contains information about an individual's health. The purpose of the document is to gather information about the patient's health conditions, the treatment they are (or were) going through, their prescribed medication, and more.

Alternate Names:

  • Health History Form;
  • Patient Medical History Form;
  • New Patient Medical History Form.

Generally, each medical organization develops its own format for medical documents (with its own stamps and seals) so that it can be easily recognized and used by all of its patients. A Medical History Form template can be downloaded through the link below.

This type of document is often used when an individual wants to provide their new physician with details relevant to their health. A simple Medical History Form can contain information about the patient's allergies, past diseases, illnesses that run in family, and other details. You might get asked to complete this kind of record while you are waiting for your doctor's appointment or before a surgery you have scheduled.

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What Is Often Included on a Medical History Form?

Commonly, a Medical History Form will include the following parts:

  1. Patient's Personal Information. This section's primary purpose is to collect the identifying details of the patient. These details can include their name, date of birth, gender, weight, height, and many more.
  2. Contact Details. The patient is usually required to designate their contact information that consists of their telephone number, email, and address. Commonly, patients are also required to provide information about their emergency contact - a person who is supposed to be contacted first in case of any urgent situation.
  3. Medical History Information. Often, this part of the document is divided into several sections that can be named the following:
    • Symptoms. In the first section the patient can be required to state whether they are suffering from any symptoms right now;
    • Conditions. Here, the patient can indicate whether they have any health conditions;
    • Medication. If the patient is under treatment by medication right now, then they must designate it here;
    • Allergies. Patients can use this section to list all allergies they have or mark that they don't have any allergies;
    • Lifestyle. Some things that we do regularly or seldom throughout our lives can impact our health condition, which is why medical history forms often include questions about the individual's habits, exercising, diets, etc.
  4. Other Details. If the patient thinks that there is other information that their doctor should know about them, then they can put it in a separate section for comments.
  5. Verification Statement and Signature. This section can consist of several statements that the patient must acknowledge, agree with them, and put their signature under it. In these statements, the patient that completed the form must verify that all of the information they presented is true and correct to their knowledge and that they allow the medical organization to collect and keep this information about them.

How Often Should Medical History Forms be Updated?

When a new patient has filled out their Medical History Form and given it back, the hospital personnel (or personnel of the medical organization where you receive help) is supposed to put it in their records and keep it there for a certain period of time before it will need to be either discarded or updated. That period of time can depend on the regulations of the place (country, state, county) where the medical organization is located.

After your medical history has been added to the medical organization record system, there is a certain number of people who can access them besides you. It includes your authorized representatives, your healthcare providers, and situations when access to your medical records is required by law. Information about disclosure of medical records is usually included in a separate section of your medical history, nevertheless, you can also contact your medical organization to learn the details.


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