Simple Medical History Template

Patient Name*

First NameLast Name

Patient Birth Date*

MonthDayYear

Patient Gender*

Patient Height (cm's)*

Patient Weight (kg's)*

Patient E-Mail*

Reason for seeing the doctor:*

Please list any drug allergies

Have you ever had (Please check all that apply)

Other illnesses:

Please list any Operations

Please list your Current Medications

Exercise

Never1-2 days3-4 days5+ days

Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan

Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day

Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day

Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day

Include other comments regarding your Medical History

General Patient Information