Use This Template

Adult Medical History Form

Use our free Adult Medical History Form template to gather information about a patient’s prior health history and help healthcare providers get an accurate feel for the patient’s current conditions and concerns. Our comprehensive template includes sections covering various aspects of a patient’s health, ranging from their overall medical history to their mental health and social history. You can easily modify any of the sections by adding your own questions or removing sections entirely if they don’t fit your needs. This version of our medical consent form is intended for adult patients. We have a template for the child version of a medical history form available as well.

We also included a simple internal section for your staff to indicate once they’ve added a patient’s medical history to their file. Using workflow statuses and the Entries page, staff members can easily monitor each entry’s progress and status.

All data collected can be made HIPAA compliant with our Enterprise plans after signing our Business Associates Agreement (BAA). Additionally, our data encryption capabilities can help ensure your data is secure both at rest and in transit.

Feel free to customize this template by adding, removing, and editing fields as you see fit. You can style this form as you please or keep your org’s branding consistent with other forms using our Organization Theme feature. You can also directly embed this form onto your practice’s website or portal, if necessary, as well.

Adult Medical History Form

Use our adult medical history form to gather a patient's current and prior medical health history.



  • Patient
  • Internal Staff


  • Incomplete
  • Submitted
  • Processed