Medical History template

A medical history form that gathers diagnosed conditions, allergies, current medications, surgical history, and family history for the care team to review — with branching that respects patients' time. Answer "No" to allergies or surgeries and the related detail questions disappear; answer "Yes" and the form asks for specifics while they're top of mind.

Use this template Start free — no card

9 questions · works on the free plan (500 responses/month) · fully customizable

2 built-in logic rules

What’s inside

The questions this template ships with — rename, reorder, or delete any of them in the builder.

01Have you ever been diagnosed with any of the following?Checkboxes

02Do you have any allergies?Multiple choice

03Please list your allergies and typical reactionsLong text

04Current medications and supplementsLong text

05Have you had any surgeries or hospital stays?Multiple choice

06Please list the procedures and approximate datesLong text

07Does anyone in your immediate family have a history of:Checkboxes

When to use this template

A new-patient packet where history arrives before the first visit, so the provider reviews it rather than transcribes it
A specialist's office collecting history from referred patients whose records haven't been transferred yet
A surgical center gathering medication and allergy lists ahead of pre-op assessments
An annual-physical refresh where patients update last year's answers instead of starting from a blank clipboard

Tips to get more from it

Two skip rules run this form: the allergy and surgery detail questions only appear after a "Yes," so most patients see seven questions, not nine
The conditions checklist includes "None of these" and allows Other — keep both, since forced choices on a medical checklist produce unreliable data for the care team
The medications question asks patients to write "none" rather than leave it blank; that distinction between "no medications" and "skipped the question" matters when staff review the chart
The template collects information for the care team to review at the visit — the ending says exactly that, and it's a framing worth keeping in any edits

Questions people ask

Can patients complete a medical history form online before their visit?

Yes. Send the link ahead of the appointment and the completed history arrives in your responses dashboard, where staff can review it before the patient is in the room.

What if a patient doesn't know all their medication dosages?

The form asks for dosages "where you know them," and the welcome text tells patients they can review answers together with the care team at the visit — it collects best-effort information, not a final record.