Medical History Template with Examples

Medical History Template

This medical history template is AI-powered to help general practitioners document critical aspects of the patient's past medical history (PMH), ensuring high-quality treatment plans and continuous care. With Heidi, the AI medical scribe for all clinicians, you can instantly generate medical histories that:

• Capture essential patient information including medical history, medications, allergies, and social history to create a complete health profile.
• Identify patterns and potential health risks by analyzing family history, chronic conditions, and past treatments. 
• Evaluate the patient’s symptoms, current medications, and lifestyle factors to support accurate diagnosis and effective treatment planning.
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What is a Medical History Template? 

A medical history form template is a structured document used to record a patient’s health information, including medical history, medications, allergies and symptoms. Healthcare providers use it to gather and organize key details to support diagnosis and treatment. 

Medical history templates are essential for consistent and thorough documentation, helping care teams identify patterns, risk factors, and underlying conditions to create a complete patient health profile.

In this article, we’ll discuss the key elements of an effective medical history template, how to customize medical history templates for different healthcare settings, and most importantly, share customizable and AI-compatible medical history templates you can use for your medical practice.

Key Elements of an Effective Medical History Template

For a medical history template to support evaluations and treatment plans, it needs to capture the right type and amount of information. Below are key details you must include to ensure your medical history template is effective:

1. Basic Patient Information

Include their full legal name, date of birth, sex, personal contact information, emergency contact details (name, relationship, phone number), and their health insurance details if applicable. Accurate information is crucial for quick identification and follow-ups.  

2. Chief Complaint (Reason for Visit)

Have a section to describe the patient’s main reason for seeking medical care. Include fields for the onset date of symptoms, description of the symptoms, e.g., pain level and frequency, and add notes for what improves or worsens the condition. This should give appropriate context for the rest of the information on the template, and helps with quicker and more accurate diagnosis. 

3. Past Medical History (PMH)

This section lists the patient’s past illnesses and chronic conditions e.g., diabetes, hypertension, surgical history (dates and types of surgery), as well as a history of hospitalizations and previous treatments. Having this information on record is essential for identifying underlying health risks. 

4. Medications, Supplements, and Allergies

This covers the patient’s current medications (name, dosage, frequency), supplements, and discontinued medications along with the reasons for stopping. Included here are the patient’s drug, food, and environmental allergies, along with the severity of their reactions.

This information helps care teams avoid drug interactions, prescribing conflicts, and potentially dangerous medical errors. 

5. Family Medical History

This part details the major health conditions within the patient’s immediate family e.g., heart disease, cancer, mental health issues, as well as hereditary conditions e.g., diabetes, genetic disorders. Documenting the patient’s family history can help identify genetic risks, and inform preventive measures.

6. Social History

This section outlines lifestyle factors such as smoking, alcohol consumption, and recreational drug use, along with exercise habits and diet. Additionally, this documents details about the patient’s occupational and living environment. These social factors influence health outcomes and the effectiveness of treatment plans. 

7. Mental Health History

Document psychiatric diagnoses e.g., depression, anxiety, if applicable, along with therapy history, current mental health medications, stress levels, and coping mechanisms. It’s important to integrate mental health into overall care since stress, anxiety, and depression can weaken the immune system, as well as affect the patient’s ability to adhere to the treatment plan. 

8. Other Providers and Specialists

Include a list of current healthcare providers and specialists involved in the patient’s ongoing evaluation and treatment, along with the date of their last visit and reasons for follow-ups. Documenting this information helps with coordination among care teams and prevents conflicts in treatment. 

How to Customize a Medical History Template for Different Healthcare Settings

While general printable medical history form templates work just fine in most cases, it’s better to customize medical history templates depending on the healthcare setting. This ensures that the information collected is relevant, efficient, and actionable for each specific use case.

Below are specific adjustments you can make to medical history templates based on specific health care settings:   

Primary Care

Primary care providers need a complete patient history so they can monitor the patient’s health over time and identify early signs of chronic issues. A medical history template for primary care must capture a broad health overview to effectively establish a baseline for ongoing and future care. Include comprehensive fields for the following:

• Past medical history and chronic conditions.
• Family history and genetic risks.
• Lifestyle and social history e.g., smoking, alcohol consumption, diet etc.

Specialist Care

In contrast with primary care providers, specialists need more targeted information to accurately assess patient conditions, and to avoid prescribing redundant or irrelevant tests. Personal medical history templates for this use case must be tailored to capture detailed, and condition-specific information such as:

• Chief complaint and the history of present illness (HPI).
• Review of systems (ROS) focused on the relevant body system e.g., cardiovascular, musculoskeletal etc. 
• Current medications to identify potential drug interactions.
• Potential diagnostic tests and specialist evaluations.

Emergency Care

ER settings require immediate access to the most relevant information so doctors can make quick, life-saving decisions. The goal is to rapidly assess and stabilize the patient, so medical history templates for emergency care should include:

• Chief complaint and the onset of symptoms.
• Allergies and medication history (to avoid adverse reactions).
• Current medications and existing health conditions.
• Emergency contacts and insurance details. 

Medical History Template Example

Here’s a free medical history template example in PDF and Google Doc form.

Download PDF | Copy Google Doc

Creating and customizing medical history form templates is critical to managing complex patient data. Unfortunately, it can also be time-consuming and error-prone when done manually. Fortunately, AI medical scribes can now simplify this process by automating data entry, ensuring accuracy, and updating patient records in real-time. 

In just 3 months after implementing Heidi, Nourish Family Nutrition saved 6,064 minutes in documentation time, reducing the administrative burden of 28 clinicians, and dramatically improving the quality of care and overall patient experience across the board.

Easily Complete Medical History Templates with Heidi

Heidi is our state-of-the-art AI medical scribe specially designed to help healthcare providers complete medical history templates in real-time. With your patient’s permission, simply hit record and let Heidi work as you go!

Here’s how Heidi helps you complete your HPI documentation:

• Transcribe – Open Heidi on your computer or mobile device and press Start so Heidi can capture your conversation in the background. For information that you don’t want to verbalize, you can type them under context notes to be considered later.
  
• Customize – After the session, simply select your preferred medical history template and watch as Heidi perfectly transcribes the details of your conversation and context notes in the appropriate format!
  
• Transform – After generating your completed medical history templates, you can ask Heidi to give additional documentation including SOAP notes as needed. 

Heidi complies with jurisdiction-specific regulations, ensuring data localization for customers in Australia, Canada, the United States, the United Kingdom, and beyond. Read more about our compliance here.

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Free Customizable Medical History Templates

Medical History Update Form Template

This template is designed to assist emergency medicine specialists to document initial patient assessments in the emergency department. It includes sections for the chief complaint, past medical history, medications, allergies, history of present illness (HPI), and review of systems (ROS) among others. 

View Template‍

Medical History Chart Template

This template assists general practitioners in capturing detailed patient histories and examination findings. It includes sections for current issues, past medical history, medications, social history, and allergies. 

View Template‍

Family Medical History Chart Template

This template is designed for family medicine specialists to document comprehensive patient visits. It includes sections for subjective symptoms, past medical history, review of systems (ROS), objective findings, and assessment and treatment plans. 

View Template

FAQs Medical History Templates

How do I format a family medical history template?

Start by creating clearly defined sections for each key element. Include fields for the patient’s basic information (name, date of birth, contact details), then follow it up with a list of health conditions within the immediate family (heart disease, diabetes, mental health issues). Add other notes to capture relevant data about generic risks and lifestyle factors that could affect health outcomes.

Can I create my own patient medical history template with Heidi?

Absolutely! We’ve designed Heidi to be highly-intuitive so you can easily create and tailor your medical history templates as needed. Review our guide on note customization and document management to get started.

How do I write more effective medical history notes?

To write medical history notes more effectively, focus on clarity, brevity, and specificity. As much as possible, use bullet points or short sentences for maximum readability and reference. Finally, ensure accuracy by reviewing and updating notes regularly. With Heidi Health’s AI medical scribe, you can automate all of these best practices.