Medical History Form

Check out our medical history form template to elevate the quality of care within your healthcare practice. Ensure that your patient information is accurate and up-to-date.

By Karina Jimenea on Mar 06, 2024.

Fact Checked by Nate Lacson.

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What is a Medical History Form?

A medical history form is a document that contains all past history of a client’s health. Medical history forms typically include information such as previous medications, treatments, surgeries, allergies, visits, referrals, and other notes. It should cover any previous details that practitioners should know when evaluating the patient and guiding their treatment, and should be comprehensive in nature. It’s very easy to get the small details confused when working with multiple clients in one practice, so it’s important that you compile effective that eliminate any misattributions and invalid treatments.

With the medical history form template, you can ensure that you’re getting the right data every time and that you’re covering all relevant healthcare information. You’ll be able to treat patients, prioritize their needs, and take into account a range of factors that could influence the efficacy of your services. It’s standardized practice and ensures you’re able to elevate the quality of care in your practice.

Printable Medical History Form Template

Check out these Medical History Form Templates to improve your medical intake process and HIPAA compliance.

How to Use This Template for Medical History Form

It can sometimes be overwhelming to know how to incorporate medical history forms and all their information - which is why we’re here to help! To effectively use the medical history form template, it is beneficial for you to follow these simple steps. 

Step One: Download the medical history template

The first thing that you need to do is download the medical history template by clicking the link. The template should open with your PDF reader software, where anyone can click to edit any section. It’s easy, intuitive to use, and also printer-friendly. 

Step Two: Give to your patients to fill out

The next step, although an obvious one, is that you need to give the medical history form to your clients to fill out. Ideally, your template is stored on the database or platform that is forwarded or handed to your patients, or you can simply print out the forms to have on file. Regardless, your patients need to complete all the sections. 

Step Three: Save the document securely 

Once your patients have completed the medical history form, you must store it in a safe place to protect the privacy of their information. This may involve scanning the file onto your work computer and uploading it to a private HIPAA-compliant database, or straight input of data from the document to the storage platform. Whatever you choose, it is imperative you have a secure way of keeping your client details.

Medical History Form Example (Sample)

If you’re interested in checking out our medical history form example template, then have a look at the link here. You can use this essential structure to guide your healthcare treatment in noting all relevant information pertaining to a client’s health. Additionally, if you would like to see an example of this filled out, feel free to check out our completed medical history form sample. 

Download this Medical History Form Example here: 

Medical History Form Example (Sample)

Who Can Use this Printable Medical History Form (PDF)?

Medical history forms are useful for healthcare practitioners who need to create an outline of a patient’s health journey. They’re a great way to keep track of all operations, check-ups, visits, referrals, and other important health information, and to ensure that you’re able to holistically evaluate clients. As a result, medical history forms aren’t exclusive to one specific discipline and can be used by any practitioner in the healthcare space that requires access to past medical interventions. Using medical history forms also means that you can safely prescribe the treatment without interference or complications of other healthcare matters.

Various healthcare professionals can benefit from medical history forms, including the following:

  1. Psychologists
  2. Psychiatrists
  3. General Practitioners
  4. Nurses
  5. Doctors
  6. Counselors
  7. Massage Therapists
  8. Physical Therapists
  9. Mental Health Therapists
  10. Occupational Therapists 
  11. Speech Language Therapists

Why is This Form Useful for Clinicians?

Medical history forms are useful for clinicians for various reasons, including the following.

  • Informed decisions - Having a patient’s medical history all available from one place means that you can see an overview of their entire healthcare journey in one quick glance. Recognizing a patient’s history means you can identify what worked and what didn’t, and make more informed decisions regarding their treatment. 
  • Simplified workflow - A ready-made medical history form allows you to cut straight to the point. Healthcare is complicated enough as it is, so don’t waste any more time! Integrate medical form templates to note all the important information without compromises. 
  • Greater organization - Using a structured medical history form template can elevate consistency across your operations. Treat each client with the same level of care, and increase standardization in your documentation processes. Improved organization means you can produce stronger client documentation, and attend to their needs more precisely.
Clinician feedback

Why Use Carepatron For Medical History Form?

Carepatron is one of the leading practice management software available that can manage and control your clinical information through a simplified approach. Used by over 10,000+ healthcare professionals worldwide, you can create your medical history forms in seconds using ready-made templates, and store them within the HIPAA-compliant software. Keep your client information safe, and elevate the quality of the content of your notes with ease. 

Not only this, but with Carepatron, you can access a multitude of features including appointment scheduling, booking, appointment reminders, medical billing and coding, video consultations and messages, online payments, as well as many others. Prioritize your patient needs by integrating sophisticated software that saves you both time and money and allows you to do what you do best; treat patients. Healthcare can be tricky but it doesn't have to be! With Carepatron, you can smoothen and streamline your operations, as well as boost the growth that you wish to see.

Medical History Software
Who completes the patient's medical history form?
Who completes the patient's medical history form?

Commonly asked questions

Who completes the patient's medical history form?

The medical history form is completed by a healthcare practitioner. While the client should have access to the medical history form, they should not have the authority to edit or create the document itself. Qualified medical professionals should be the only point of contact when it comes to creating and drafting medical history forms, and this is non-negotiable.

When should a medical history form be updated?

A medical history form should be updated anytime there's new information pertaining to a client's health. Ideally, this is after every visit with the patient, and even a simple outline of the date and time when you meet with the patient should suffice. It is important to remember that the medical history covers all details of the patient's prior appointments. You should never finish an appointment with nothing added to the document. This is a big no-no in healthcare and can lead to misinformation and mistreatment.

Who should review the patient's medical history form?

Only authorized users should have access to the medical history form. If a client requests to view the medical history form they should have full access to it, however, most of the time medical professionals, such as doctors, nurses, and general practitioners, will review the medical history to guide treatment. Any clinician that is evaluating your client, whether this is in another provider or organization or otherwise, needs to have access to their medical history information for sufficient assessment.

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