Go Back

Learn More

123FormBuilder
Form Templates
Medical forms
Medical History Form

Ambulance Checklist Form
Ambulance Transfer Form
Authorization for Disclosure of Protected Health Information
Authorization Request Form
Blood Donation Form
Body Measurement Form
Botox Consent Form
Cancel Appointment Form
Caregiver Consent Form
Child Assessment Form
Child Care Authorization Form
Child Care Emergency Form
Child Health Survey
Child Intake Form
Chiropractic Intake Form
Claim Information Form
Client History Form
Cosmetic Surgery Survey
Dental Assessment Form
Dental Assistant Evaluation Form
Dental Claim Form
Dental Clearance Form
Dental Enrollment Form
Dental Estimate Form
Dental Examination Form
Dental Implant Consent Form
Dental Insurance Breakdown Form
Dental Insurance Form
Dental Insurance Verification Form
Dental Procedure Medical History Form
Dental Records Release Form
Dental Referral Form
Dental Reimbursement Form
Dental Screening Form
Dental Treatment Consent Form
Dental Treatment Plan Form
Dentistry Contact Form
Disability Verification Form
Doctor Appointment Form
Doctor Diagnosis Form
Doctor Referral Form
Drug Prior Authorization Request Form
Emergency Contact Form
Emergency Information Form
Endodontist Patient Registration Form
Endodontist Referral Form
Enrollee Prescription Drug Claim Form
Facial Intake Form
First Aid Checklist Form
First Aid Quiz
Flu Vaccine Consent Form
Food Allergy Form
General Dentist Patient Registration Form
General Surgery Consent Form
Health Assessment Questionnaire
Health Checklist Form
Health Evaluation Form
Health Insurance Claim Form
Health Insurance Evaluation Survey
Health Insurance Information Form
Health Insurance Marketplace Statement
Health Screening Form
Health Survey
Home Delivery Pharmacy Prescription Order Form
Hospital Admission Form
Hospital Discharge Form
Hospital Evaluation Form
Hospital Patient Satisfaction Survey
Hospital Registration Form
Hospital Visitation Form
Immunization Exemption Form
Immunization Record Form
Immunization Record Request Form
Immunization Waiver Form
Indemnity Form
Informed Consent Form
Laboratory Test Request Form
Massage Consent Form
Massage Health History Form
Massage Therapy Consent Form
Massage Therapy Intake Form
Maternity Claim Form
Medicaid Application Form
Medicaid Complaint Form
Medicaid Transportation Form
Medical Authorization Form
Medical Card Application Form
Medical Certificate Form
Medical Consultation Form
Medical Declaration Form
Medical Examination Form
Medical Examination Report Form
Medical Information Form
Medical Insurance Form
Medical Order Form
Medical Permission Form
Medical Record Audit Form
Medical Record Transfer Request
Medical Records Release Form
Medical Records Request Form
Medical Reimbursement Bill Form
Medical Reimbursement Claim Form
Medical Release Form
Medical Summary Form
Medical Travel Form
Medical Treatment Authorization Form
Medicare Application Form
Medication Administration Record
Medication Disposal Form
Medication List Form
Member Reimbursement Form
Mental Health Intake Form
Mental Health Survey
Newborn Questionnaire
Nursing Assessment Form
Nursing Home Application Form
Nursing Report Form
Nutrition Consultation Form
Occupational Therapy Progress Note
Online Bill Payment
Online Medical Questionnaire
Ophthalmology Referral Form
Oral Surgery Consent Form
Oral Surgery Patient Registration Form
Oral Surgery Referral Form
Organ and Tissue Donation Form
Organ Donation Form
Pathology Request Form
Patient Admission Form
Patient Appointment Request Form
Patient Assessment Form
Patient Demographic Form
Patient Discharge Form
Patient Engagement Survey
Patient Exit Survey
Patient Health Questionnaire
Patient History Form
Patient Intake Form
Patient Monitoring Form
Patient Note Entry Form
Patient Nutrition Assessment Form
Patient Pain Assessment Form
Patient Progress Tracking
Patient Registration Form
Patient Revocation Request Form
Patient Satisfaction Survey
Patient Survey Questionnaire
Pediatric Consent Form
Pedodontic Patient Information Form
Periodontal Referral Form
Permission To Treat Form
Personal Representative Request
Pharmacy Complaint Form
Pharmacy Registration Form
Physical Clearance Form
Physical Exam Form
Physical Therapy Evaluation Form
Physician Referral Form
Physician Satisfaction Survey
Physician Verification Form
Police Medical Questionnaire
Prescription Drug Claim Form
Prescription Form
Prescription Refill Request Form
Proof Of Immunization Form
Provider Satisfaction Survey
Psychiatric Evaluation Form
Psychological Assessment Form
Psychology Intake Form
Psychology Referral Form
Psychotherapy Intake Form
Referral Request Form
Request a Routine Medical Appointment
Request for Access to Protected Health Information
Request for Accounting
Request for Confidential Communications
Request for Diagnosis and Treatment Code Information Form
Request for Restriction of Use and Disclosure of PHI
Request Routine Dental Appointment Form
Request to Amend Protected Health Information
Request to Inspect a Copy of Clinical Record
Request to Obtain a Copy of Clinical Record
Request to Restrict the Use of Confidential Information
Safety Declaration Form
School Entry Health Form
School Medication Form
School Medication Record
Self Referral Form
Social Psychology Survey
Social Work Intake Form
Sports Physical Form
Sports Therapy Consultation Form
Statement of Disagreement
Student Health Record Form
Student Insurance Claim Form
Test Report Form
Therapy Consent Form
Training Requirement Form
Treatment Consent Form
Universal Medication Form
Vaccine Order Form
Veterinary Prescription Form
Weight Loss Tracking Form
Wound Assessment Form

Medical History Form Template

Use this medical history form template at your clinic to complete patient records and file up their past medications, vaccinations, major illnesses and surgical procedures.

AVAILABLE ON FREE PLAN

This template is available in the FREE plan, with many perks:

100 submissions per month
Digital signatures
Use your own logo and branding
Share and publish it anywhere
Notification emails

Continue with template

Join 1.5 million happy customers that build forms & surveys with 123FormBuilder

Customize template

See how

Customize this medical history form template on 123FormBuilder with simple drag & drop. No coding is needed. Select from a variety of form fields to use and enable data encryption that will keep the data confidential and safe. Upon request, we provide a special package for HIPAA compliance.

Publish template

See how

Publish the medical history form on your website or share it with your patients directly on email. It's up to you and it's easy as 1-2-3. All you have to do is copy & paste the final code of the medical history form once you are done editing it.

Collect & manage data

See how

Receive all medical history entries of your patients in a secure repository that comes with the form. Form there, you have complete access to manage the data as you please.

Optimize your flow

See how

Start optimizing your paperwork by switching to 123FormBuilder. You can create a copy of this medical history form with the click of a button and the registration process takes only 60 seconds, if you don't have an account at the moment. So what are you waiting for? Get this medical history form template for free.