Health History Template

June 18, 2011

A Health history template is a readymade format of a document that helps to find out the medical history of an individual. These types of templates prove to be helpful in treating an individual for any particular disease or ailment and finding out the possible risks if any.

Sample Health History Template

Name _____________ [the person’s name]

Address ______________ [address of same]

Date of last medical test _________ [(dd/mm/yyyy) date needs to be filled]

Name of physician___________ [mention his/her name]

Address ____________ [mention address of same]

Immunisations taken __________________ [mention each immunisation taken]

Last date of immunisation_________________ [mention the date of each]

Medicines needed and why _________________ [name the medicines that you consume and the ailment]

Any current health risk ___________________ [mention the disease, if any]

Any previous elaborate medical treatment taken _______________ [mention past treatments]

Any allergies ______________ [fill your allergies]

Dietary restraints________________ [mention any food related restriction]

Any mental or psychological ailment _______________ [mention if any mental illness]

Medicines needed _______________ [mention the drug used]

Signature _________________ [sign of the applicant]

Date __________dd/mm/yyyy______

Download Health History Template in Word Format

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