Free printable medical history form

A new doctor, a specialist, an urgent care desk: each one hands over a clipboard and asks for the same facts. The National Institute on Aging suggests asking for the medical history form before a visit so it can be filled in at home. A one-page summary that you fill in once, keep up to date and take to every visit makes each new clipboard quicker, whether the history is your own or a parent's.

What's in the free file

• One page, the health summary, in large print.
• About the person: name, date of birth, blood type (if known), and how they communicate, such as the languages they speak or a hearing aid they wear.
• Doctors and pharmacy: the main doctor and the pharmacy, each with a phone number.
• Five boxes under Health: conditions, allergies, medicines taken now, past surgeries, and devices and implants.
• Who to call: two people, with their phone numbers.
• The last lines: the insurance plan and its phone number, where important papers are kept, and the date the page was last updated.
• Large print. The title is 26 point, the labels 18 point and the section headings 20 point.
• Fill-in fields. Type into every line and box before you print, in the free Adobe Acrobat Reader, or print it blank and write by hand.
• No pictures and no advice: a blank form only.
• Sizes: US Letter and A4, as two files.

What goes on each line?

The insurance line asks for the plan's name and phone number only. Keep the member number on the card itself, so the page can sit in a folder or on a clipboard without giving it away.

How to fill in the form

1. Gather what you have first: pill bottles or the medication list, insurance cards, the doctors' cards, and any papers from a hospital stay.
2. Fill in the lines that rarely change: name, date of birth, blood type, the main doctor, the pharmacy and the people to call.
3. Write the conditions and past surgeries with a year next to each, as near as you know it. "About 2015" is fine.
4. Write each allergy with what happens, or "none known". Never leave the allergy box blank: a blank box can't be told apart from a box nobody filled in.
5. For medicines, write the main ones or "see medication list". A full list belongs on its own page: our large-print medication list is free too.
6. Write the date next to Updated, and change it each time you check the page.
7. Keep it where you will find it, in a folder or binder that goes to appointments, and make a copy for the person who would step in.

What should a medical history include?

MedlinePlus suggests starting a personal health record with any allergies, a list of medicines and supplements with the doses, major illnesses and surgeries with dates, any history of illnesses in the family, and the dates and results of tests, along with the name, birth date, blood type and emergency contacts. The one-page summary holds the first part of that list. A fuller history adds:

• A line for each health condition, with the year it started and the doctor for it.
• Surgeries and hospital stays, with dates, the hospital and what happened.
• Allergies and vaccines, with the reaction to each allergy and the dates of each vaccine.
• Tests and results, with the date of each.
• Family health history. The CDC suggests collecting information about parents, sisters and brothers, children, grandparents, aunts, uncles, nieces and nephews: their major health conditions, the age at which each was found, and the age and cause of death for those who have died.

The National Institute on Aging publishes free worksheets for some of these, including a family health history worksheet. Our full Large-Print Medical History Form has a page for each, behind the health summary.

Medical history form or emergency information sheet?

They overlap, and many families keep both. The emergency sheet is for a stranger in a hurry: it lives on the fridge, and paramedics or a visiting relative read it in a minute. The medical history form is for appointments: it goes in the folder, and it holds more of the past, such as surgeries, devices and where papers are kept. Our guide to the emergency information sheet for the fridge explains the sheet, and our page of questions to ask your doctor goes in the same folder.

Who fills in a medical history form?

• You, for yourself, before a visit to a new doctor or a specialist.
• A family caregiver, for a parent or a partner whose history they help keep. The NIA suggests that a family member or friend can come to appointments too.
• The person and a family member together. If the person you help can still write, ask them to fill in what they can, and fill in the rest with them.
• One copy per person. Two people in a house means two forms.

What this form is not

It is a blank page for your own notes, not a medical record: the records are kept by the doctors' offices and hospitals. It does not ask for or give advice. A new doctor's office will usually still want its own intake form; the summary is what you copy from to fill it in.

Our full Large-Print Medical History Form adds pages for health conditions, surgeries and hospital stays, allergies and vaccines, tests and results, family health history, and a family checklist with a column for each side of the family.

A medical history form is one of the printable forms for family caregivers that families keep together in one binder.

Frequently asked questions

What is a medical history form?

A medical history form is a page that keeps a person's main health facts in one place: health conditions, allergies, medicines, past surgeries, doctors and who to call. Doctors' offices ask for the same facts at a first visit, and a filled-in form makes them quicker to give.

What should I write on a medical history form?

Start with the name, date of birth, allergies and the medicines taken now. Add health conditions and past surgeries with the year of each, the main doctor and pharmacy, and two people to call. Write the date you last checked the page.

Can I fill in the medical history form on my computer?

Yes. The free form has fill-in fields you can type into before you print, in the free Adobe Acrobat Reader, and the typed text in a long line shrinks to fit. You can also print it blank and write by hand.

How often should I update a medical history form?

Whenever something changes: a new condition, a surgery, a new allergy or a change of doctor. Write the new date next to Updated each time, so anyone reading it knows how current it is.

Is a medical history form the same as a medical record?

No. Medical records are kept by the doctors' offices and hospitals. A medical history form is your own summary of the main facts, kept at home and taken to appointments.