Patient History Form Template

You can use this online patient history form sample to create a record of a patient's medical history. It requires no technical skills.

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About this template

This patient history form template is used by health care and medical providers to create a conclusive record of a patient’s medical history so they can provide the best medical services to their patients. You can improve the experience your patients have with your clinic by offering them the possibility of filling in this form, directly online or on a electronic device while waiting at the clinic. This is a safe, compliant and modern way of automating the way you collect your patients data. And with our drag-and-drop form builder, you don’t need to worry about customizing this form in any way you need it and share it online. It’s a piece of cake! As for compliance, you can opt for our HIPAA suite for forms on 123FormBuilder. GDPR is included on the entire platform and forms.

Frequently Asked Questions

What is a patient history form?

This form collects all medical-relevant patient data and offers a generous overview of the health history for that patient, allowing doctors and medical staff to provide the best medical care services.

What should a medical history form include?

This form comes with a lot of pre-defined questions covering the patient’s medical history in terms of past illnesses, treatment, medications, allergic reactions, medical visits etc.

How to customize the template?

Gather new patients’ information ahead of time with an online form based on this patient history form template. There’s no technical knowledge required—just drag and drop to insert and change any questions as you need. You can collect data in all the most useful formats, including radio buttons, Likert scales, text areas, and more. Even add spam protection with a smart Captcha field. Add the logo of your practice and use professional, soothing colors for a finishing touch.

How to publish the template?

You can use your patient history form template just about anywhere online. For example, copy and paste the embed code to insert it into your website. In addition, you can use the handy share buttons in the form editor to send a patient survey by email or share on social media. No matter where you distribute your form, it works on any size device thanks to its smart, responsive layout.

How to collect and manage data?

The sensitive data transmitted through this patient history form is sent securely to a database accessible in your 123FormBuilder dashboard. There you can export any record as a PDF to place in the patient’s folder. You may also choose to export all records to Excel or CSV for use in your own patient tracking system. 123FormBuilder also integrates with a large number of popular cloud services, which means it can automatically funnel data to your file management, marketing, CRM, and payment gateway apps.

How to optimize processes?

Provide more thoughtful, thorough patient care by giving them a patient history form to complete in advance of their appointment. This will provide you with the opportunity to look over new patients’ health history prior to their arrival. Rather than have patients arrive 15 minutes early and fill out a paper form, give them the convenience of completing the medical questionnaire on their own time. Furthermore, you’ll save staff time that would otherwise be spent entering handwritten details into your computer system.

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