Large-Print Medical History Form

What’s inside

10 pages in each PDF

1. Start here: what's inside and how to print it1 page
2. Health summary on one page: name, date of birth, blood type, communication, main doctor and pharmacy with phone numbers, conditions, allergies, medicines taken now, past surgeries, devices and implants, two people to call, the insurance plan and its phone number, and where important papers are kept1 page
3. Health conditions: 15 lines for the condition, the year it started, the doctor and notes1 page
4. Surgeries and procedures, 7 lines (year, what was done, hospital and surgeon, notes), and hospital stays and emergency visits, 6 lines (dates, hospital, reason, notes)1 page
5. Allergies and reactions, 6 lines with a tick box for no known allergies, and vaccines, 7 lines (vaccine, dates, where it was given, notes)1 page
6. Tests and results: 15 lines for the date, the test, the result and notes1 page
7. Family health history: mother, father, 3 lines for sisters and brothers, the 4 grandparents, 2 lines for children and 2 blank lines, each with the age now or at death and health conditions1 page
8. Family health checklist: 15 common conditions and 3 blank lines, with a tick box for the mother's side, the father's side and sisters and brothers, and a notes column1 page
9. Personal-use license and a note about the pages2 pages

How it works

1. Type the person's name before you print: it fills in on every form page. Every line fills in too, the tick boxes tick on screen, and long names shrink to fit.
2. Or print the pages and write by hand.
3. Fill in one copy for each person, and write the date next to Updated whenever a page changes.
4. Take the health summary to appointments, and keep the pages together in a folder or binder.

Sizes and format

• 2 PDF files: US Letter (8.5 x 11 in) and A4, 10 pages each
• Large print: page titles 26 pt, labels 18 pt, table headings 14 to 16 pt
• The fill-in fields and tick boxes need the free Adobe Acrobat Reader
• Blank forms, text and lines only: no pictures, no advice
• The insurance line asks for the plan's name and phone number, not a member number
• Instant download. No physical item is shipped.

The files

• US LetterPDF, 10 pages, 331 KB
• A4PDF, 10 pages, 331 KB

Your license

For personal use in one household: print as many copies as you need, and please don't share or resell the files.