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Medical history form template

A complete record of your health history for doctors.

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How to make a medical history form

  1. 1

    Check the questions: rename, add or delete any field, or change how it’s answered.

  2. 2

    Add your organisation’s name, a contact line and your logo if you like.

  3. 3

    Choose fillable PDF, printable PDF, Word or HTML, and the paper size.

  4. 4

    Download the medical history form and share it, print it or add it to your website.

About this medical history form

A medical history form gives a doctor the background they need in minutes: conditions you’ve had, operations and hospital stays, current medications, allergies, illnesses that run in your family, lifestyle habits and vaccinations. Clinics use it for new patients, and many families keep a filled-in copy for each person to take to appointments.

Everything you type stays on your device: the form is built in your browser and nothing is uploaded. Save the fillable PDF and update it after each change in your health.

What’s on the medical history form

The template has 10 sections and 17 questions. Every one can be renamed, moved or deleted.

  • Patient: Full name; Date of birth; Blood group (choose one: A+, A−, B+, B−, AB+, AB−, O+, O−, Unknown); Height and weight
  • Conditions: Conditions (tick all that apply: Asthma, Diabetes, High blood pressure, Heart disease, Thyroid, Epilepsy, Arthritis, Depression or anxiety, Cancer, Kidney disease, None); Other conditions
  • Surgeries and hospital stays: Surgeries table (Procedure or reason, Year, Hospital)
  • Medications: Medicines table (Medicine, Dose, How often, Reason)
  • Allergies: Allergies (medicines, foods, other) and reactions
  • Family history: Family table (Relative, Condition, Age at diagnosis)
  • Lifestyle: Smoking (choose one: Never, Former, Current); Alcohol (choose one: Never, Occasionally, Weekly, Daily); Exercise (choose one: Rarely, 1–2 times a week, 3+ times a week)
  • Vaccinations: Vaccinations and dates (Tetanus, Hepatitis B, COVID-19, Flu…)
  • For women: Pregnant or possibly pregnant? (yes or no); Date of last period
  • Signature: Signature with date

Tips

  • Bring your medicine packets to fill in doses accurately.
  • Ask older relatives about family history once and record it.
  • Keep a copy in your phone for emergencies abroad.

Four ways to save it

A fillable PDF has typing boxes, tick boxes and choices built in. A printable PDF gives clean boxes and writing lines for pen and paper. The Word file can be edited further, and the HTML code adds the same questions to a website. Browse more form templates, or design a completely different layout in the custom form builder.

Frequently asked questions

Why does family history matter?

Many conditions, such as heart disease, diabetes and some cancers, are more likely if close relatives had them. Doctors use it to decide on screening.

How often should I update my medical history?

After any new diagnosis, operation or medication change, and at least once a year.

Is anything I type sent to a server?

No. The editor runs in your browser and builds the file on your device. Atifo has no server that could receive your form or the answers on it.

Can I put the medical history form on my website?

Yes. Choose “HTML” to copy ready-made form code with labels and a simple style. Set the form’s action to the address that should receive submissions, such as your own form handler.

Can people fill in this medical history form on a phone?

Yes. Choose “Fillable PDF” and send the file. It opens in the Files or Drive app on Android, Files on iPhone, and any browser on a computer, where people can type their answers and save the result.

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