Sample Medical History Forms

History taking is one of the main pillars of medical sciences. It sets the foundation for proper management of the patient when he or she comes to the hospital. We can trace it down to the very old practices of the medical sciences that history taking always led to some very important diagnosis, discoveries of diseases, and most importantly, the management of these diseases.

History taking has always been defined as the science and art through which a physician digs out important points and clues that help him reach the diagnosis and treat the patient with minimum hassle and confusion.

There are a number of diseases that are diagnosed purely on the basis of history and that is why, in medical schools, history taking is taught right from the beginning of medical education.

Description of medical history form


A medical history form always begins with the introduction of the patient. It is a very important section of the form as it sets the identity of the patient. Information about his age, date of birth, sex, ethnicity, and marital status along with the contact and address is also mentioned in the introduction of a history form.

Age is asked because it has been proven that some diseases are age specific and do not exhibit in other age groups. For example, presbyopia is a problem of aging and can never appear at the age of 14 years. Similarly, some diseases are specific to certain ethnic and racial groups and we don’t often see them in other groups.

Current or past medications

In this particular medical history form, we are mainly concerned with the medical history which begins with the history of medications. As doctors, we are always concerned and interested in knowing the past or present history of medications. This tells us a lot about the medical history of the patient and also guides us about our future strategy regarding medications. This is also important because certain drugs if prescribed and administered together, may show drug interactions that are undesirable sometimes.

Past surgical history

Past surgical history is really important because past surgery definitely modifies the anatomy inside a human being. For example, a pregnant woman with a previous caesarian section must be different in anatomy than a woman with past 4 surgeries. The number of adhesions increases with an increased number of past surgeries.

History of Past illnesses

History of past illnesses is also important. For example, a person suffering from hypertension or diabetes needs careful management of his current illness. Similarly, we are very much interested in knowing if the patient has had tuberculosis in the past. It is because there are high chances of reactivation of the foci spreading the disease to other people around him.

History of vaccinations

The history of vaccination is the most aspect of a medical history form. We do need to know if the patient was vaccinated against major communicable diseases. If he is not vaccinated, he may be a potential danger to the community around him as a carrier of infection.

See a few sample forms given below

File: Word (.doc) 2007+ and iPad Size 148 Kb | Download


File: Word (.doc) 2007+ and iPad Size 559 Kb | Download


File: Word (.doc) 2007+ and iPad Size 114 Kb | Download


File: Word (.doc) 2007+ and iPad Size 279 Kb | Download


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