Medical history form template

Medical History Form

Date: Date

Patient details

| Item | Details |

| --- | --- |

| Patient Name | Patient Name |

| Medical Record Number | Medical Record Number |

| Date of Birth | Date of Birth |

| Height and Weight | Height and Weight |

Illnesses and operations

| Item | Details |

| --- | --- |

| Chronic Conditions | Chronic Conditions |

| Previous Operations and Dates | Previous Operations and Dates |

| Previous Admissions | Previous Admissions |

Current medicines

| No. | Medicine | Dose | Since |

| --- | --- | --- | --- |

| 1 | Medicine 1 | Dose 1 | Since 1 |

| 2 | Medicine 2 | Dose 2 | Since 2 |

| 3 | Medicine 3 | Dose 3 | Since 3 |

| 4 | Medicine 4 | Dose 4 | Since 4 |

Allergies and habits

| Item | Details |

| --- | --- |

| Drug or Food Allergies | Drug or Food Allergies |

| Smoking | Smoking: yes / no |

| Family Medical History | Family Medical History |

| Pregnancy | Pregnancy: yes / no / not applicable |

Patient: Patient Name

Signature: Signature

Reviewing Nurse or Doctor: Reviewing Nurse or Doctor