Medical history form template
A personal medical history form with conditions, surgeries, medications, allergies, family history and your doctors, to fill before a new patient visit.
- 🇺🇸 US format · Letter size
- Free
Fill in what you need. The preview updates as you type.
What you type is not saved on our server.
Your own record, not a diagnosis
This form is for your own records and for the paperwork a new doctor, dentist or hospital asks you to fill in. Not medical advice. Share with your doctor. Keep a copy at home and update it when a medication or diagnosis changes.
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Medical History Form
For my own records and new patient paperwork
1. Patient
| Name | Jordan Lee | Date of birth | March 14, 1984 |
|---|---|---|---|
| Phone | (555) 010-0000 | Emergency contact | Taylor Kim, Spouse |
| Emergency contact phone | (555) 010-0202 | Date completed | October 5, 2026 |
2. Conditions (check all that apply, now or past)
| Heart and lungs | □ High blood pressure □ High cholesterol □ Heart disease □ Irregular heartbeat □ Blood clots □ Stroke □ Asthma □ COPD □ Sleep apnea |
|---|---|
| Diabetes, thyroid, kidney, liver | □ Type 1 diabetes □ Type 2 diabetes □ Prediabetes □ Thyroid disease □ Kidney disease □ Liver disease □ Hepatitis |
| Digestive, bones, joints | □ Acid reflux □ Ulcer □ Crohn's or colitis □ Arthritis □ Osteoporosis □ Back problems |
| Cancer and blood | □ Cancer (type and year below) □ Anemia □ Bleeding disorder |
| Mental health | □ Depression □ Anxiety □ Bipolar disorder □ ADHD □ Eating disorder |
| Other | □ Seizures □ Migraines □ Autoimmune disease □ Tuberculosis □ None of the above |
| Details (type, year, treatment) |
|---|
3. Surgeries and hospital stays
| Year | Surgery or hospitalization | Hospital |
|---|---|---|
| 2019 | Appendectomy | St. David's Medical Center, Austin TX |
| 2012 | Wisdom teeth removed | Outpatient |
4. Current medications, vitamins and supplements
| Medication or supplement | Dose and how often | Reason |
|---|---|---|
| Lisinopril | 10 mg once a day | Blood pressure |
| Atorvastatin | 20 mg at night | Cholesterol |
| Vitamin D | 2, | Supplement |
5. Allergies and reactions
| Medications | Penicillin (rash) |
|---|---|
| Foods | Shellfish (swelling) |
| Other (latex, bee stings, contrast dye) | Latex |
6. Family history (parents, siblings, grandparents)
| Relative | Condition | Age at diagnosis |
|---|---|---|
| Mother | Type 2 diabetes | 58 |
| Father | High blood pressure | 50 |
| Maternal grandfather | Heart attack | 67 |
7. Lifestyle
| Smoking or vaping | □ Never □ Former (quit year: ______) □ Current (amount per day: ______) |
|---|---|
| Alcohol | □ None □ Occasional □ Weekly (drinks per week: ______) □ Daily |
| Exercise | □ Rarely □ 1 to 2 times a week □ 3 or more times a week |
| Caffeine and sleep | Cups a day: ______ Hours of sleep: ______ |
8. My doctors
| Primary care | Dr. Casey Nguyen, Hill Country Family Medicine, (555) 010-0606 |
|---|---|
| Specialists | Dr. Sam Park, cardiology, (555) 010-0808 |
| Pharmacy | |
The information above is accurate to the best of my knowledge. I will update it when something changes. October 5, 2026 Patient or guardian signature: Jordan Lee | |
Not medical advice. Share with your doctor.
How to use it
Type your details once: medications with dose and reason, surgeries with the year and hospital, allergies, family history and your doctors. The form prints on two pages with the conditions as check boxes you tick by hand, lifestyle questions and a signature line. Fill the check boxes in pen, sign, and copy the answers into the clinic's own intake form or hand this one over when they accept it.
Keep the file. Every new provider asks the same questions, and a dated copy at home means you are not rebuilding the list of medications from memory in a waiting room. Update it when something changes and print again.
Things to watch
Include over-the-counter drugs, vitamins and supplements; they interact with prescriptions. For family history, first-degree relatives (parents, siblings, children) matter most, with the age at diagnosis. The form does not ask for a Social Security number or insurance ID on purpose; give those on the clinic's own forms, not on a sheet you keep in a drawer.
Calculators that go with this
Frequently asked questions
Why is there no insurance section?
Insurance and ID numbers belong on the clinic's registration form, which they store under HIPAA rules. This form is the medical story you carry between providers. Keep the two apart.
Can I fill it in for my parent or child?
Yes. Type their details and sign as the guardian or the person with power of attorney. The emergency contact should then be you or another family member who can answer the phone.
Where do I keep the ongoing lists?
Use the medication log template for the week-to-week checking and copy its list here when you update the history. The blood pressure and blood sugar logs give the numbers a new doctor will ask about.
Is what I type saved anywhere?
No. Everything stays in your browser and nothing is sent to our server. If you refresh the page it is gone, so print, save a PDF or download the DOCX when you are done.