Medical History Form

Medical History Form — Form Fields

This healthcare template includes 12 fields. Capture comprehensive patient medical history including conditions, surgeries, family history, and lifestyle. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Have you ever been diagnosed with any of the following? (checkboxes, optional) — options: Heart Disease, Cancer, Diabetes, Stroke, High Blood Pressure, Depression / Anxiety, Thyroid Disorder, None of the Above — Select all that apply
• Past Surgeries (long text, optional) — Include procedure and approximate year
• Current Medications (long text, optional)
• Allergies (long text, optional) — Include type of reaction
• Family Medical History (checkboxes, optional) — options: Heart Disease, Cancer, Diabetes, High Blood Pressure, Mental Health Disorders, None / Unknown — Conditions present in immediate family (parents, siblings)
• Do you smoke or use tobacco? (multiple choice, required) — options: Currently, Formerly, Never
• Do you consume alcohol? (multiple choice, required) — options: Daily, Weekly, Occasionally, Never
• Exercise Frequency (dropdown selection, required) — options: Daily, 3-5 times per week, 1-2 times per week, Rarely, Never
• Additional Medical Information (long text, optional) — Anything else your provider should know
• Patient Signature (signature, required) — I certify this information is accurate