Medical History Form Template
Comprehensive personal medical history snapshot — for new providers, surgeries, second opinions, or personal records.
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PERSONAL MEDICAL HISTORY ═══════════════════════════════════════════════════════════════════════ Patient: Jordan Alex Taylor DOB: June 12, 1985 History prepared: May 4, 2026 ═══════════════════════════════════════════════════════════════════════ CHRONIC / ONGOING CONDITIONS Mild exercise-induced asthma — diagnosed 1999. Well controlled with as-needed albuterol. Episodic migraine without aura — diagnosed 2007. ~2 episodes/month, sumatriptan-responsive. ═══════════════════════════════════════════════════════════════════════ PAST SURGERIES 2014 — Laparoscopic appendectomy, no complications. 2008 — Wisdom tooth extraction (general anaesthesia, uneventful). ═══════════════════════════════════════════════════════════════════════ PAST HOSPITALIZATIONS 2014 — Appendectomy admission, 2-day stay. No other adult hospitalisations. ═══════════════════════════════════════════════════════════════════════ CURRENT MEDICATIONS Sumatriptan 50 mg — as needed for migraine, max 2x/week (Dr. Chen, OHSU). Multivitamin OTC, daily. Albuterol HFA inhaler — 2 puffs as needed (Dr. Park, Pacific NW Pulmonology). ═══════════════════════════════════════════════════════════════════════ ALLERGIES PENICILLIN — diffuse hives at age 9, no anaphylaxis. Cephalosporins tolerated. PEANUTS — anaphylaxis at age 12, EpiPen carried. No latex, no contrast media, no other known drug allergies. ═══════════════════════════════════════════════════════════════════════ IMMUNIZATIONS COVID-19: primary series + bivalent booster 2024. Influenza: annual. Tdap: 2021 (next due 2031). HPV: full series 2003. MMR, varicella, hepatitis B: full childhood series. ═══════════════════════════════════════════════════════════════════════ MENTAL HEALTH HISTORY Generalised anxiety, mild — no formal diagnosis, brief course of CBT 2019. No medications. Currently stable. No history of depression, mania, psychosis, eating disorder, or self-harm. ═══════════════════════════════════════════════════════════════════════ SEXUAL / REPRODUCTIVE HISTORY Sexually active, monogamous heterosexual relationship. Last STI screen: negative, 2025. No pregnancies, no children. Regular menses, no fertility concerns. ═══════════════════════════════════════════════════════════════════════ FAMILY HISTORY Mother: type 2 diabetes (age 58), hypertension. Living, age 67. Father: coronary artery disease, CABG age 64. Deceased age 71 (heart attack). Sister: healthy, age 38. Maternal grandmother: breast cancer, deceased age 73. Maternal grandfather: stroke, deceased age 68. ═══════════════════════════════════════════════════════════════════════ SOCIAL / LIFESTYLE Alcohol: 2-4 drinks/week, social. Tobacco: never. Illicit drugs: never except occasional cannabis (legal in OR). Diet: omnivorous, balanced. Exercise: 3-4x/week. Occupation: software consultant (sedentary, screen-heavy). Marital status: single, no dependants. ═══════════════════════════════════════════════════════════════════════ CURRENT PROVIDERS Primary care: Dr. Lin Chen, OHSU Internal Medicine — +1 503 555 0411. Pulmonology: Dr. Asha Park, Pacific NW Pulmonology — +1 503 555 0422. Dental: Dr. Martin Lee, Riverside Dental — +1 503 555 0418. ═══════════════════════════════════════════════════════════════════════ PATIENT ATTESTATION _______________________________ Date: ____________________ Jordan Alex Taylor This history is provided for clinical and informational purposes. It is the patient's good-faith summary of records; treating providers should verify clinically-significant items against primary medical records.
About this template
A medical history form prepared by the patient is one of the most valuable documents a person can carry. It speeds new-patient intake, supports second opinions, gives ER staff a starting point in an emergency, and fills the gaps that fragmented healthcare records leave behind. The federal push toward patient access (the 21st Century Cures Act and the ONC Information Blocking Rule) means more patients now get full access to their records electronically — but those records often live across multiple portals (one per provider system) and rarely consolidate cleanly. A self-prepared history is the consolidated view. Update it once or twice a year and keep a copy in your wallet, glove box, or phone notes app. The most actionable sections in any setting are allergies (medication errors are the leading category of preventable hospital harm), current medications (drug interactions kill thousands annually), and chronic conditions (drives risk-stratification for any acute presentation). Family history is increasingly important as genetic-testing access expands. For surgery, the surgical history and anaesthesia complications are essential — anaesthesiologists ask "have you ever had problems with anaesthesia?" routinely, and this form gives a defensible answer. For mental health and reproductive history, the patient controls disclosure — these are sensitive areas with state and federal protections (42 CFR Part 2 for substance use, state laws for HIV, mental health, reproductive). Provide what helps; redact what does not.
When to use it
- Establishing care with a new primary-care provider or specialist.
- Going in for surgery or anaesthesia.
- Seeking a second opinion.
- Travelling for medical care abroad.
- Emergency department preparation — keep a copy in your wallet.
- Annual personal review of your own health.
What to include
- Chronic conditions, past surgeries, past hospitalizations.
- Current medications (with dose, frequency, prescriber).
- Allergies (with the specific reaction).
- Immunization status.
- Family history (especially first-degree relatives).
- Social/lifestyle and current providers.