• Features
  • PDF Templates
  • Fillable PDF Forms
  • FAQ
  • Welcome to JotForm!

    Customize forms, save time & effort and collect online payments easily.

    Welcome Back!

    Customize forms, save time & effort and collect online payments easily.


    Simple Medical History Template

    by JotForm Cloned 4,165

    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.


    Collect your online responses with JotForm and turn them into professional, elegant PDFs automatically.

    Simple Medical History Template
    Please list any drug allergies
    Etiam preti
    Have you ever had (Please check all that apply)
    Emotional Disorder
    Phaidra Ainsbury
    Other illnesses
    Birth Date
    Please list any Operations
    Cras non velit n
    Height (cm's)
    Please list your Current Medications
    Praesent l
    Weight (kg's)
    1-2 days
    Reason for seeing the doctor
    Integer ac neque.
    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?
    Include other comments regarding your Medical History
    Etiam pretium iaculis justo.
    Simple Medical History Template

    More templates like this

    Short Medical History

    Medical History

    Medical History Record PDF template is mostly used in order to provide significant information about the health history, care requirements, and risk factors of the patient to doctors. It is for collecting data from the patients.

    Patient Medical Record

    Medical History

    Medical History Record PDF template lets you collect the patient's data such as personal information, contact information in an emergency case, general medical history. By using this sample, the doctor ensures the patient's better care and treatment.

    Patient Intake

    Medical History

    Patient intake PDF template is easy for patients to fill out and designed to get the doctor the most important information. Patients can fill out their information on a computer or tablet using our patient intake pdf sample.


    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.