Fillable Form Medical History

What is a Medical History Form?

A medical history form is a record of information about your health. Hospitals and doctors review your health history to be able to determine the best treatment for you. A medical history form includes information about your allergies, illnesses, past surgeries, vaccinations, and results of physical exams and tests.

How to fill out a Medical History Form?

Page 1

NOTES

The answers and information that you provide on this form will help your doctors understand your medical concerns and conditions better.

If there are questions that make you feel uncomfortable, feel free not to answer them.

If you cannot remember specific details, best estimates will do.

Name

Enter your full name.

Phone

Enter your home and work number.

Street

Enter the street of your residence.

City

Enter the city of your address.

State

Enter your state of residence.

Zip

Enter the zip code.

Age

Enter your age.

Height

Enter your height in feet.

Weight

Enter your weight in pounds.

Occupation

Enter your occupation.

Gender

Enter your gender. You may choose M for Male and F for Female.

Date of Birth

Enter your date of birth.

Place of Birth

Enter the place or hospital of your birth.

Marital Status

Enter your marital status.

Family Physician

Provide the name of your family physician.

Social Security No.

Enter your social security number.

Emergency Contact

Provide the name of your emergency contact.

Telephone number

Provide the telephone number of your emergency contact.

Reference person

Provide the name of your reference person.

Acupunture history

Answer this question whether you have been treated by acupuncture in the past or not.

Main problem(s)

Provide a definition of your main health problem(s) you would like to get help for.

Problem or disease

Provide your health problem or disease.

Beginning of disease or problem

Provide information on how long ago this problem began.

Extent of the problem

Provide the extent of interference this problem causes to your daily activities. For example, the problem affects your work, sleep, etc.

Duration of the problem

Provide specific information on how long you have been experiencing this problem.

Diagnosis

Answer this question whether you have been given a diagnosis for this problem or not.

Treatment

Provide the type of treatment you have tried to resolve this problem.

Past Medical History

Provide information about your past medical history and include the dates.

Significant Illnesses

Fill out this line if you have significant illnesses such as cancer, diabetes, hepatitis, high blood pressure, heart disease, rheumatic fever, thyroid disease, seizures, or venereal disease.

Surgeries

Fill out this line if you have had surgeries before. Provide a brief description.

Significant trauma

Fill out this line if you have significant trauma caused by a vehicular accident, falls, etc.

Birth history

Fill out this line if you have birth history such as prolonged labors, forceps delivery, etc.

Allergies

Fill out this line if you have allergies.

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Family Medical History

Choose the disease that your family has a history with. You may choose from the following options:

• Diabetes
• Cancer
• Stroke
• High Blood Pressure
• Seizures
• Asthma
• Allergies
• Heart disease

Occupation

Occupational Stress

Provide a brief description if you experience occupational stress.

Regular Exercise Program

If you have a regular exercise program, briefly describe your program.

Medicines taken within the last two months

Provide the medicines you have taken within the last two months. Include vitamins, over-the-counter drugs, herbs, supplements, etc.

Restricted diet

Answer this question if you are or have ever been on a restricted diet.

Kind of diet

If you are or have ever been on a restricted diet, provide the kind of diet.

Average daily diet

Provide a description of your average daily diet during morning, afternoon, and evening.

Cigarettes

If you smoke cigarettes, enter the amount of packs you smoke per day.

Coffee, Tea, Cola

If you drink coffee, tea, or cola, enter the amount you drink per week.

Alcohol

If you drink alcohol, enter the amount you drink per week.

Drugs for non-medical purposes

Provide a description of the drugs you take for non-medical purposes, if you take any.

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General

Choose from the following options if you experience them.

• Poor appetite
• Fever
• Sweat easily
• Localized weakness
• Bleed or bruise easily
• Peculiar tastes or smell
• Sudden energy drop — If you choose this option, provide the time of day when you experience this.
• Poor sleeping
• Chills
• Tremors
• Poor balance
• Weight loss
• Strong thirst for hot or cold drinks
• Fatigue
• Night sweats
• Cravings
• Change in appetite
• Weight gain

Skin and Hair

Choose from the following options if you experience them.

• Rashes
• Itching
• Dandruff
• Change in hair or skin texture
• Ulcerations
• Eczema
• Loss of hair
• Hives
• Pimples
• Recent moles

If you have any other hair or skin problems, describe them.

Head, Eyes, Ears, Nose and Throat

Choose from the following options if you experience them.

• Dizziness
• Glasses
• Poor Vision
• Cataracts
• Ringing in ears
• Sinus problems
• Grinding teeth
• Teeth problems
• Headaches — Describe where and when.
• Concussions
• Eye strain
• Night blindness
• Blurry vision
• Poor hearing
• Nose bleeds
• Facial pain
• Jaw clicks
• Migraines
• Eye pain
• Color blindness
• Earaches
• Spots in front of eyes
• Recurrent sore throats
• Sores

If you have any other head or neck problems, describe them.

Cardiovascular

Choose from the following options if you experience them.

• High blood pressure
• Irregular heartbeat
• Cold hands or feet
• Blood clots
• Low blood pressure
• Dizziness
• Swelling of the hands
• Phlebitis
• Chest pain
• Fainting
• Swelling of the feet
• Difficulty in breathing

If you have any other heart or blood vessel problems, describe them.

Respiratory

Choose from the following options if you experience them.

• Cough
• Bronchitis
• Difficulty in breathing when lying down
• Production of phlegm — Describe the color.
• Coughing blood
• Pneumonia
• Chest pain
• Pain with a deep breath

If you have any other respiratory problems, describe them.

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Gastrointestinal

Choose from the following options if you experience them.

• Nausea
• Constipation
• Black stools
• Bad breath
• Abdominal pain or cramps
• Chronic laxative use
• Vomiting
• Gas
• Blood in stools
• Rectal pain
• Diarrhea
• Belching
• Indigestion
• Hemorrhoids

If you have any other problems with your stomach or intestines, describe them.

Genito-urinary

Choose from the following options if you experience them.

• Pain on urination
• Urgency to urinate
• Decrease in flow
• Frequent urination
• Unable to hold urine
• Impotence
• Blood in urine
• Kidney stones
• Sores on genitals

Do you wake up to urinate?

Answer YES if you wake up to urinate.

Describe how often you wake up to urinate.

Urine color

If your urine has a particular color, describe it.

If you have any other problems with your genital or urinary system, describe them.

Pregnancy and Gynecology

Choose from the following options if you experience them. This section only applies to women.

• If you have been pregnant, provide the number of pregnancies
• If you have experienced miscarriages, provide how many
• Provide the period between your menses
• If you have given birth, provide how many times
• If you have aborted, provide how many times
• Provide the duration of your menses
• If you have given birth prematurely, provide how many times
• Provide your age when you first had menses
• Provide the date of your first menses if you remember it
• Unusual character (heavy or light)
• Painful periods
• Vaginal discharge
• Changes in body or psyche prior to menstruation
• Clots
• Vaginal sores
• Last PAP
• Breast lumps

Birth control

Answer YES if you practice birth control.

Type and duration

Enter the type of birth control and how long have you been practicing it.

Musculoskeletal

Choose from the following options if you experience them.

• Neck pain
• Back pain
• Hand or wrist pains
• Muscle pains
• Muscle weakness
• Shoulder pain
• Knee pain
• Foot or ankle pains
• Hip pain

If you have any other joint or bone problems, describe them.

Neuropsychological

Choose from the following options if you experience them.

• Seizures
• Areas of numbness
• Concussion
• Bad temper
• Dizziness
• Lack of coordination
• Depression
• Easily susceptible to stress
• Loss of balance
• Poor memory
• Anxiety

Treatment for emotional problems

Answer YES if you have been treated for emotional problems.

Suicide attempt

Answer this question if you have considered or attempted suicide before or not.

If you have any other neurological or psychological problems, describe them.

Comments

Fill out this field if you have any other concerns or problems that you want to address.

Frequently Asked Questions About A Medical History Form

Why is a medical history form important?

Medical history forms serve as a record of events and treatment given to a patient. The most common form used by medical professionals is the health history questionnaire, which is designed to identify risk factors for disease. Additionally, it assists in determining if the individual has any problems requiring immediate attention and with certain diseases or conditions that require follow-up or monitoring. The medical history form also allows for the physician to gain a better understanding of the patient and their needs and further contribute to the future course of treatment.

The information documented on an individual’s medical history form can vary among different forms, but it usually contains demographic information such as the person’s name, gender, age, and ethnicity. It also includes a section for past illnesses, medical conditions and surgeries received. Finally, some forms might include a section for family history of diseases or cancer among other things. The information collected from a patient’s medical history form assists a physician in making a diagnosis and treatment plan for his or her patient.

What does a medical history form include?

A medical history form contains questions that help determine a patient's medical history. The form is divided into multiple sections, each pertaining to a different area of the patient's medical history. For example, one section could be for allergies while another could be for past surgeries. It must be comprehensive enough to provide the doctor with all of the information that they need to properly treat their patient.

What is the purpose of a health history questionnaire?

A health history questionnaire or a medical history form is used by a physician to complete a patient's medical record. The information that is collected allows the physician to identify potential problems and decide on the best course of action for treatment. Some of the information collected is also beneficial for research purposes. The medical history form allows the physician to compare this patient's case with similar ones in order to increase their understanding of a disease or specific condition.

Medical history forms are also used by researchers conducting clinical trials on new drugs and therapies that may help treat a condition or disease. By collecting data on large groups of people who have a specific condition or disease, researchers can determine the potential effectiveness of a new treatment.

The form is completed by the patient and kept in his or her medical record for future reference. Some patients keep copies of their medical history forms with them at all times in case they need to go to another facility and need emergency treatment. This way, the other healthcare provider can read about their current condition and use that information to determine the best course of action for treatment.

How does your medical history affect your health?

Your medical history affects your health in a way you might not realize. For example, if you have a family history of breast cancer, you may be more likely to develop it yourself. Moreover, your family's medical history may influence your risk of developing other conditions, too.

The same can be said about mental illness. Your parents' mental health plays a role in your risk of developing certain disorders, but there are plenty of other factors to consider as well.

A medical history serves as a guide to your past, present, and future, as your health depends on what happened before you were born, and the health of your parents. It can also serve as a guide to the health of future generations.

When and how a medical history is obtained?

Your medical history is obtained when you go to a healthcare facility for a medical appointment or checkup. You tell the medical professional all of your symptoms and what you think might be wrong with you, as well as past medical issues and current medications. You might also be asked the names of any family members who have had that same condition — or an indicator disease — so that the facts can be checked against your story for verification purposes.

In addition to reviewing your medical history, a healthcare professional obtains a complete physical examination upon you, from head to toe. In addition to the hands-on time with your body, he or she also consults with other medical professionals such as laboratory staff and imaging technicians in order to achieve a diagnosis.

Diagnosis is just one step toward health care. After identifying an issue, the healthcare professional will recommend treatments for it. The recommended treatments might be drugs, medications, surgery, or a mixture of treatments. The treatment plan will be unique to you because your needs and preferences are taken into consideration as part of the process. The healthcare professional might also ask you to make certain lifestyle changes in order for your treatments to be most effective. These could include eating more greens, adding exercise to your daily routine, or getting enough sleep.

Your medical documents will then be added to your medical history, which is a part of what will be required in your medical records.

What are the reasons medical records are kept?

Medical records are kept to ensure continuity of quality healthcare and to support legal requirements. This is true for medical records in both the private and public sectors. Records are kept for a number of reasons:

• To protect the health of individuals by ensuring a documented account of services provided to them, including previous conditions or illnesses that may require future treatment. In this way, medical staff provides the most accurate information to ensure the best future care.
• To maintain quality of care by providing a record of treatments provided to patients so that they may be available for reference purposes. This is especially important when care has been given by more than one member of staff or in different places.
• For legal reasons, e.g. to prove the standard of care provided by a medical professional or organization
• To provide continuity of service. Therefore, if an individual is likely to require future healthcare treatment whether in the short term — i.e. requiring immediate and continuing care — or long term — i.e. needing specific treatments over a number of years — it is important that their records are kept secure.
• With regard to older people, it is especially important that medical professionals keep accurate documentation of illnesses and treatments given as this may be used as evidence should there be any question or dispute over entitlement for benefits or services provided. It also allows them to receive the best possible care in old age should they need continuing care.
• To ensure continuity of care for babies and young children, it is important that any significant incidents or accidents are reported to social services or the police if criminal activity is suspected. Professionals must also consider whether they may be required to report any incidents involving neglect, abuse, or endangerment. This ensures that parents do not repeat unsafe practices and investigations are carried out to understand an incident completely.
• To make sure that individuals receive the correct treatments, e.g. medication — individuals may have allergies or conditions that mean they can take certain drugs but not others — or surgery — e.g. if patients have had previous operations for similar problems, it is important to ensure that details of the operation and post-operative care are documented.
• To protect against insurance fraud — e.g. if a patient claims they have not had a certain treatment and this is not evident in their medical records but has received that treatment elsewhere.

How do I write my medical history?

To write your medical history, you can use a medical form or simply write it on sheets of paper.

What should be on a medical history form?

A medical history form should have a detailed history of the patient's physical and mental health records. It helps doctors to diagnose the patient's problem and treat them faster. It includes information about past illnesses, hospitalizations, operations, family history of diseases along with details of any allergies they have. Doctors usually check for the following before diagnosing a patient:

• Family History - Diseases which run in a family may be more common in a patient.
• Medications - Any allergies or side effects from medication can affect the diagnosis of a disease.
• Past Medical History - Patients’ past illnesses and hospitalizations help doctors to understand their present condition more clearly.
• Social History - Alcohol, tobacco use, and others that may affect a patient's health and can cause diseases like cancer.
• Review of Systems - A patient’s review of their symptoms will help the doctor to determine the illness.

What is a medical history document?

A medical history document is a record of your entire history with medical treatment. This form is utilized by hospitals, clinics, and doctor's offices to keep track of all treatments you have had. Such information can include everything from injuries to illnesses over the years as well as allergies to medications that have been prescribed for you.

It provides your doctor or healthcare provider with a full picture of your medical history. This is important because certain treatments may not be effective on you if you have had an adverse reaction to a particular medication or treatment in the past. The medical history document will help ensure that this doesn't happen by giving your doctor or healthcare provider all of the details upfront. Moreover, it is your responsibility to keep your medical history document updated, as any changes in medications or treatments will need to be stated on the form.

How do you ask past medical history questions?

Asking about the past medical history of your patient should be done in a standard fashion to prevent missing any important information on their medical history. This helps establish how serious the patient's condition is, what treatment options are available and also helps prevent harm to the patient.

There are different methods of asking about the past medical history depending on your specialty or what you would want to know about during an encounter with a new patient.

You can interview your patient and write down the answers on a medical history form or you can record the patient's past medical history on a computer or tablet for ease of access.

Why do doctors ask for medical history?

It is standard practice that doctors ask for medical history to properly diagnose a patient. Doing so is not only crucially important for making an accurate diagnosis, but also for evaluating the patient's lifestyle habits and risk factors. Nevertheless, a patient should answer the medical questions honestly, no matter whether these concern lifestyle habits or are just queries regarding the patient's medical history. Otherwise, the doctor might prescribe the wrong treatment and worsen the patient's health condition instead of improving it.

Why is it important to be honest in consulting medical history?

It is important to be honest in consulting medical history since a patient may not reveal pertinent information unless directly asked. As a result, physicians often rely on medical tests to uncover an illness or injury that the patient fails to report. The medical tests, in turn, generate more questions and concerns for patients who wonder what these tests are going to do to them.

Is it illegal to change medical records?

Changing medical records is a serious crime that nobody should be fooled into thinking is harmless. But the penalties for this crime are inadequate, and they don't seem to work as a deterrent. Updating of medical records should only be done by the people who are meant to do it. Moreover, previous medical records should be kept as they may serve as a reference in the future.

Who is responsible for medical records?

Healthcare providers are responsible for keeping and maintaining medical records. They are tasked with two primary goals: to safeguard the confidentiality of patient information and to make sure that patients receive appropriate care. This means that healthcare providers are only sharing the medical records if it is relevant to their care.

Many people are unaware that there are laws in place to protect their privacy. HIPAA (The Health Insurance Portability and Accountability Act) was put into place to protect the confidentiality of an individual's medical information. The act specifies how long healthcare providers must keep records, who they can share information with, and the penalties for violations.

Is it possible to have medical records deleted?

Yes, it is possible to have your medical records deleted. Patients can request to have their records expunged or destroyed.

Can any doctor see your medical history?

You have a legal right to your medical records and only those whom you have given permission to can access them. You have a legal right to know who has had access to your health information and why. Your medical records are protected by law from unauthorized access, use, or release by those who work in the healthcare system, without your permission or authorization, unless they believe you are a risk of serious harm to yourself or others. Doctors may only access your medical records when they are providing you with medical care, they are looking for information that will help them treat you properly, or if they need to follow up on your care. Doctors may not access your medical records for other reasons without first getting your permission.

Who has access to your mental health records?

Your mental health records are private documents. Those who can have access to them are limited to your doctors, nurses, therapists, social workers, and, under specific conditions, the police. They may not be even accessed by your mother, your best friend, or your coworker. They may not be shared without written permission from you yourself.

Can anyone ask for your medical records?

Not everyone can ask for your medical records. You are the only one who can give permission to release them to others. Nevertheless, according to the Health Insurance Portability and Accountability Act (HIPAA), there are some exceptions regarding this.

You can grant access to your medical records if you want someone to be able to provide follow-up care or coordinate your care with other providers. You may also grant access for purposes of payment, which is to share your records with another healthcare provider or health plan that will be serving you. You can also allow access based on your request for a copy of the record to take to another provider, which is called "transfer."

Is medical information private?

Your medical information is private and is not available to others unless you grant permission.

Does your medical record follow you?

Your medical records follow you throughout your life. From the moment you're born, medical professionals file away each of your health data points in patient records. As you age and grow, these records evolve with you — along with changes to state and national standards. Even medical records of deceased people do not expire. The dead don't need their data anymore, but healthcare providers hold onto it. After all, it could be useful to future patients.

Related articles:

• What is My Medical History
• The Components of a Medical Record