Free printable
Medical History Form
Free to print, copy and share. No signup and no email address needed. If it's useful to people you work with, you're welcome to link to this page.
Fill this in once, keep it on top of your records, and update it whenever something changes. Bring it to every new clinician, urgent care visit and hospital admission. Last updated by me on:
About me
Name:
Date of birth:
Emergency contact (name, relationship, phone):
Insurance and member ID:
Preferred pharmacy and phone:
My clinicians
| Name | Specialty | Phone | Portal / notes |
|---|---|---|---|
Conditions I have been told I have
| Condition | Year first noted | Who manages it |
|---|---|---|
Medicines, vitamins and supplements
| Name | Dose | How often | What it is for | Started |
|---|---|---|---|---|
Allergies and reactions
| To what (medicine, food, other) | What happened |
|---|---|
Surgeries, procedures and hospital stays
| What | When | Where |
|---|---|---|
Immunizations
| Vaccine | Date(s) |
|---|---|
Family health history
Conditions your parents, brothers, sisters and grandparents have had, and the age when each started, if you know it.
| Relative | Condition | Age it started |
|---|---|---|
In an emergency, call 911. If you are thinking about suicide or are in crisis, call or text 988. From pockethealth.pro/templates/medical-history. Free to copy and share. General information, not medical advice.