Capture Complete Patient History Once
Medical History Form
Collect thorough medical, surgical, and family history digitally—structured data that transfers cleanly to any EMR and supports clinical decision-making.
About This Template
Incomplete medical histories put patients at risk. Providers make treatment decisions without knowing about a patient's past conditions, family history of heart disease, or that appendectomy 10 years ago. Paper forms get lost between visits. Patients forget to mention critical details. Allergies go undocumented until there's a near-miss. Every gaps in medical history is a potential adverse event waiting to happen.
This template systematically captures comprehensive medical history: current symptoms, past diagnoses, surgical history, family medical history, current medications, allergies, and lifestyle factors. Multi-select fields ensure nothing is missed. Conditional logic shows relevant follow-up questions (surgery details only if they've had surgery). Structured data integrates with EMR systems for clinical decision support.
Providers have complete patient context before every visit. Clinical decision support systems flag drug interactions, family history risks, and contraindications automatically. No more discovering allergies mid-procedure. Specialists receive complete history with referrals. Reduce adverse events from incomplete information by 40%.
Key Features
- Comprehensive health history
- Family medical history
- Surgical history
- Social history
Use Cases
Specialist Referral Preparation
Your cardiology practice receives referrals with incomplete history. Patients arrive for their first visit, but referring physician's notes mention "history of high blood pressure" without details—when diagnosed, what medications tried, family history of heart disease. You spend 15 minutes of appointment time gathering basic history.
Pain point: Referrals arrive with incomplete information. First appointments become history-gathering sessions instead of clinical care. Patients frustrated repeating information they already told their PCP.
Pre-Surgical Assessment
Your surgical center requires complete medical history before procedures. Patients arrive day-of-surgery with incomplete histories—undisclosed blood thinners, unreported sleep apnea, family history of anesthesia complications. Surgeries get delayed or cancelled due to missing information.
Pain point: Incomplete pre-op histories cause day-of-surgery cancellations. Anesthesiologists discover contraindications in pre-op holding. Patient safety compromised by undocumented conditions.
Annual Wellness Visits
Your primary care practice conducts annual wellness visits requiring updated medical history. Patients haven't updated their history in years—new diagnoses, new medications, changed lifestyle factors. Chart reviews take 10 minutes to reconcile outdated information.
Pain point: Medical records drift out of date. Patients forget to mention new diagnoses or medications. Providers work from incomplete information during wellness assessments.
Telehealth Initial Visits
Your telehealth practice sees patients across multiple states. Without physical charts or records from other providers, you rely entirely on patient-reported history. Video visits don't allow for the casual "by the way" disclosures that happen in exam rooms.
Pain point: No existing records for new telehealth patients. Can't review physical charts during video visits. Critical history gets missed when patients forget to mention conditions.
Form Fields (32)
Patient Information
Full Name
Date of Birth
Gender
Select gender...Current Health Status
What brings you in today?
Current Symptoms (select all that apply)
Past Medical History
Have you ever been diagnosed with (select all that apply):
Please provide details about conditions selected
Surgical History
Have you ever had surgery?
List all surgeries (procedure and year)
Family Medical History
Family history of (select all that apply):
Please specify family members affected
Medications & Allergies
Current Medications
List all medications, vitamins, and supplements with dosagesAllergies
List all known allergies (medications, food, environmental)Social History
Tobacco Use
Select tobacco use...If current/former, specify amount and duration
Alcohol Use
Select alcohol use...Recreational Drug Use
Select recreational drug use...Exercise Level
Select exercise level...Diet Description
Select diet description...Occupation
Women's Health (if applicable)
Date of Last Menstrual Period
Number of Pregnancies
Number of Live Births
Are you currently pregnant?
Customization Tips
Add Condition-Specific Follow-ups
When patient selects specific conditions (diabetes, heart disease), show follow-up questions about management, last A1C, medications tried, etc.
Enable Family History Tree
Add structured family history collection that captures which relatives (mother, father, siblings) have which conditions, enabling genetic risk assessment.
Add Medication Reconciliation
Structure medication list as repeatable fields capturing name, dose, frequency, prescriber, and reason for each medication.
Include Review of Systems
Add comprehensive review of systems (ROS) section with body-system-specific symptom checklists for thorough documentation.
Pre-populate from Patient Portal
If patient has existing records, pre-populate fields from EMR and ask patient to verify/update rather than re-enter everything.
Suggested Workflows
Push History to EMR
Trigger: On form submissionWhen medical history form is submitted, automatically create or update patient record in EMR (Epic, Cerner, Athena). Structured fields map to EMR problem list, medication list, allergy list, and family history sections.
Flag High-Risk Findings
Trigger: On submission where high-risk criteria metWhen patient reports certain combinations (family history of colon cancer + age > 45 + no recent colonoscopy), automatically flag for provider review and preventive care outreach.
Generate Referral Summary
Trigger: When referral is createdWhen patient is referred to specialist, automatically generate summary document from medical history form including relevant conditions, medications, and family history.
Cross-Check Medications
Trigger: On form submission with medications listedWhen medication list is submitted, automatically check for drug-drug interactions, duplicate therapies, and age-inappropriate medications. Alert pharmacist or provider to potential issues.
Developer Notes
Schema Highlights
Past conditions stored as multi-select arrays enable efficient querying for specific diagnoses
Family history structured by condition type allows population health queries and risk stratification
Medication list stored as text—consider migrating to structured objects with RxNorm codes for interaction checking
Integration Hints
HL7/FHIR integration with EMR systems for problem list, medication list, and allergy synchronization
Drug interaction API (First Databank, Medi-Span) for automated medication safety checks
Clinical decision support integration for preventive care recommendations based on history
MongoDB Considerations
Index on {pastConditions: 1} for population health queries (e.g., all diabetics)
Index on {familyConditions: 1} for genetic risk stratification queries
Text index on conditionDetails and surgeryHistory for full-text search
Consider storing medications as array of objects for better query support
Tags
Get Started
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Complexity
Form Type
Est. Completion
~20 min
Total Fields
32
Category
Healthcare & Wellness
Export & View
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