Simple Medical History Template

    by JotForm Cloned 2,157

    Every doctor wants to know their patients' medical histories. If you want to collect the medical history information and record these data as a pdf, JotForm will help you! First of all, you can use this medical history form template for gathering your patients' information for instance name, birth date, gender, height, weight, email, their drug allergies, illnesses, operations, medications, healthy & unhealthy habits such as a frequency of exercise, a frequency of alcohol consumption, a frequency of caffeine consumption and a frequency of smoking.

    Once you have collected these medical data, you can record them as a pdf by using this medical history PDF template. In addition, you don't need to be worried about the safety of data, because our forms are HIPAA compliant.

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    Simple Medical History Template
    100%
    Date
    26/9/2018
    PATIENT MEDICAL HISTORY
    Please list any drug allergies
    Donec ut ma
    PATIENT INFORMATION
    Have you ever had (Please check all that apply)
    Asthma
    Emotional Disorder
    Veronique Wyson
    Other illnesses
    Duis co
    Birth Date
    3/11/3618
    Please list any Operations
    Nulla tempus.
    Height (cm's)
    4
    Please list your Current Medications
    Proin leo
    Weight (kg's)
    6
    HEALTHY & UNHEALTHY HABITS
    Exercise
    1-2 days
    Reason for seeing the doctor
    Duis consequat dui nec
    Eating following a diet
    I don't have a diet plan
    Alcohol Consumption
    3-4 glasses/day
    Caffeine Consumption
    1-2 cups/day
    Do you smoke?
    No
    Include other comments regarding your Medical History
    Proin leo odio, porttitor id, consequat in, consequat ut, nulla. Sed accumsan felis.
    Simple Medical History Template

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    Disclaimer

    Noth­ing on this site is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment.