Medical History Form
Take a full history before the first appointment, so clinical time goes on the consultation rather than on filling in a paper form.
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Opens in the builder. Nothing is saved until you edit it. Or ask Claude or ChatGPT to build it.
- Fields
- 14 questions
- Layout
- Classic, every question on one page
- Theme
- Default, switchable in the preview
- Updated
- 11 August 2026
Categories
- Healthcare form templates
- Healthcare Forms
- Intake Forms
- Patient Forms
Ideal for
- Clinics
- GP surgeries
- Physiotherapists
- Private practice
Best used in
- New patient registration
- Pre appointment intake
- Annual reviews
About this template
A history taken on paper in the waiting room is rushed, hard to read, and has to be typed up by somebody afterwards. Sent as a link before the appointment, it gets filled in at home where the patient can check the name of the medication they take, and it arrives legible and already searchable.
The conditions checklist is followed by a single open field for dates and treatment rather than a separate question per condition. That keeps the form short for the majority who tick one box or none, while still capturing the detail that matters for anyone with a longer history. Allergies gets its own field because it is the one answer clinical staff need to find in under a second.
Add a next of kin section if you see patients under sedation, and add a rule so the smoking follow up only appears for the answers that need it. If you handle records under HIPAA or UK GDPR, review retention before you collect anything.
Templates are a starting point, not legal or professional advice. Where a form carries consent, medical, or contractual wording, have somebody qualified review it against the rules that apply to you before you publish.
Fields in this template
- Full name*Short text
- Date of birth*Date
- Contact number*Phone
- Email addressEmail
- Home addressAddress
- Have you ever been diagnosed with any of the following?Multiple choice
- Please give dates and treatment for anything you tickedLong text
- Medication you take regularlyLong text
- AllergiesLong text
- Past operations and hospital staysLong text
- Relevant family historyLong text
- Do you smoke?Single choice
- Alcohol in a typical weekDropdown
- Signature*Signature
Every field can be renamed, reordered, made optional, or removed once the template is open in the builder.
Build this form by asking Claude or ChatGPT
Connect Deoochform to Claude, ChatGPT, or any assistant that supports MCP, then send it the message below. It creates the medical history form from this template in your account and replies with a link. You can ask it to add, remove, or reword questions in the same chat before you share the form.
Make me a form in Deoochform from your Medical History Form template, then send me the link to share.
New to this? See how to connect your assistant. You sign in with your browser, so there is no key to copy.
Frequently asked questions
- What should a medical history form ask?
- Contact details, current and past conditions with dates, medication, allergies, family history, and lifestyle. Taking it before the appointment keeps clinical time on the consultation.
- Is this form suitable for patient data?
- It stores submissions against your account over HTTPS. Before using it clinically, check the questions and your retention period against the health data rules in your jurisdiction.
- Can patients fill it in before they arrive?
- Yes, and that is the point. Send the link with the appointment confirmation and the history is on file before the patient sits down, rather than written on a clipboard in the waiting room.
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