Medical History Form
I. Personal Information
First Name:
Last Name:
Date of Birth:
Gender:
Street Address:
City/Suburb:
State/Province:
Postal/Zip Code:
Phone Number:
Email:
Emergency Contact
First Name:
Last Name:
Phone Number:
Relationship
Primary Care Physician
First Name:
Last Name:
Phone Number:
Email:
Insurance Information
Provider:
Group Number:
Policy Number:
II. Chief Complaint/Reason for Visit
What brings you in today?
When did you first notice this problem?
How long has it been going on?
Where is the problem located?
How severe is it ? (1=Not Severe, 10=Very Severe)
Factors that improve your symptoms:
Factors that worsen your symptoms:
What other symptoms have you noticed?
III. Past Medical History
Have you ever been diagnosed with any chronic medical conditions (e.g., diabetes, hypertension, asthma, heart disease, arthritis, etc.)?
Which ones?
Have you ever had any surgeries or hospitalizations?
Which ones? Please list them.
Description | Date | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 | |||
4 | |||
5 | |||
6 | |||
7 | |||
8 | |||
9 | |||
10 |
Have you ever had any serious injuries or accidents?
Please describe.
Have you ever been diagnosed with any mental health conditions (e.g., depression, anxiety, bipolar disorder)?
Which ones?
Do you have any known allergies (medications, foods, environmental)?
Which ones? Please list them.
Description | Reaction | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 | |||
4 | |||
5 | |||
6 | |||
7 | |||
8 | |||
9 | |||
10 |
Have you ever had any blood transfusions?
When?
Have you ever had any infectious diseases (e.g., chickenpox, measles, hepatitis)?
Which ones?
IV. Current Medications
Please list all medications you are currently taking (prescription, over-the-counter, herbal supplements, vitamins), including dosage and frequency:
Medication Name | Dosage | Frequency | ||
|---|---|---|---|---|
A | B | C | ||
1 | ||||
2 | ||||
3 | ||||
4 | ||||
5 | ||||
6 | ||||
7 | ||||
8 | ||||
9 | ||||
10 |
V. Family History
Has anyone in your immediate family (parents, siblings, grandparents) had any of the following:
Heart disease
Stroke
Diabetes
Cancer
High blood pressure
Mental health conditions
Other:
What cancer type?
Which mental health conditions? Please describe.
Are your parents and siblings living?
Living
Not Living (Deceased)
Cause of death:
VI. Social History
Do you smoke or use tobacco products?
Amount:
Duration:
Do you drink alcohol?
Amount:
Frequency:
Do you use recreational drugs?
Please specify.
Occupation:
Marital Status:
Do you live alone or with others?
Alone
With others
Do you exercise regularly?
Type:
Frequency:
What is your typical diet?
Do you feel safe in your home environment, and why?
VII. Review of Systems
General:
Have you experienced any unexplained weight loss or gain, fatigue, fever, or chills?
Which ones?
Skin:
Have you noticed any rashes, itching, changes in moles, or other skin problems?
Which ones?
Head, Eyes, Ears, Nose and Throat:
Have you had any headaches, vision problems, hearing loss, earaches, nasal congestion, sore throat, or difficulty swallowing?
Which ones?
Respiratory:
Have you experienced any shortness of breath, cough, wheezing, or chest pain?
Which ones?
Cardiovascular:
Have you had any chest pain, palpitations, or swelling in your legs?
Which ones?
Gastrointestinal:
Have you experienced any abdominal pain, nausea, vomiting, diarrhea, or constipation?
Which ones?
Genitourinary:
Have you experienced any changes in urination, pain with urination, or blood in your urine?
Which ones?
Musculoskeletal:
Have you experienced any joint pain, stiffness, or muscle weakness?
Which ones?
Neurological:
Have you had any headaches, dizziness, seizures, numbness, tingling, or weakness?
Which ones?
Endocrine:
Have you experienced any excessive thirst, hunger, or urination?
Which ones?
Hematologic/Lymphatic:
Have you experienced any easy bruising or bleeding, or swollen lymph nodes?
Which ones?
Mental Health:
Have you had any feelings of sadness, anxiety, or difficulty sleeping?
Which ones?
X. Other Information
Is there anything else you would like to tell the doctor?
Form Template Instructions
Form Template Instructions
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Strengths:
Comprehensive Coverage:
- It includes all essential sections: personal information, chief complaint, past medical history, current medications, family history, social history, review of systems, and an open-ended "other" section.
- It addresses physical and mental health aspects, which is crucial for holistic care.
Structured Format:
- The form is organized logically, making it easier for patients to follow and for clinicians to review.
- The use of "yes/no" questions and fill-in-the-blank sections helps to standardize the information collected.
Detailed Inquiries:
- The questions are generally specific and detailed, allowing for a thorough understanding of the patient's health.
- The inclusion of examples (e.g., "diabetes, hypertension, asthma") helps patients understand the questions.
Safety Considerations:
- The inclusion of questions about home safety is a valuable addition, addressing potential social determinants of health.
Potential Areas for Improvement:
Clarity and Conciseness:
- While comprehensive, some questions could be rephrased for greater clarity and conciseness. For example, the "Review of Systems" section, while thorough, is very long.
- Consider breaking up long questions into smaller more digestible sections.
Specificity in Certain Areas:
- In the "Family History" section, consider adding a space to indicate the age of onset for certain conditions, as this can be clinically relevant.
- In the social history section, consider adding questions about sleep quality.
Digital Adaptation:
This form would benefit greatly from digital adaptation. Digital forms can:
- Use branching logic to tailor questions based on patient responses.
- Pre-populate information from previous visits.
- Allow for easier data entry and retrieval.
- Provide drop down menus, and other selection tools to improve accuracy.
Cultural Sensitivity:
- While the form is generally well-written, it's important to be mindful of cultural differences that may influence how patients interpret and respond to questions.
- Consider translating the form into common languages within your patient population.
"Marital Status" Expansion:
- As previously discussed, consider adding a space for "domestic partnership" or other options to ensure inclusivity.
General Insights:
Patient-Centered Approach:
- The form's purpose is to gather information, but it's essential to remember the patient's experience.
- Explain the purpose of the form and assure patients that their information is confidential.
Clinician Efficiency:
- A well-designed form improves clinician efficiency by providing a structured and comprehensive overview of the patient's health.
- Ensure that the form is easy to read.
Data Quality:
- The quality of the information collected depends on the clarity of the questions and the patient's ability to understand and respond accurately.
- Provide assistance to those who have trouble reading, or understanding the form.
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