Medical history templates are used by the doctors to maintain the medical history of any patient. This helps in correct diagnosis and treatment of a disorder or illness.
Sample Medical History Template
________________________________
[Name of the patient]
________________________________
[Age and gender of the patient]
Present health concerns: Currently, I am suffering from ______________________________
___________________________________________________________________________
___________________________________________________________________________
Medication Dose Times per day
___________________________________ _____________ _______________
___________________________________ _____________ _______________
Allergies or Reaction to Food, Medication, other agents
Name of Agent Type of Reaction
___________________ _____________________________________________
___________________ _____________________________________________
Personal medical history: [Choose the ones that are applicable to you]
__________ Heart diseases
__________ Diabetes
__________ High Cholesterol
__________ Thyroid Problem
__________ Cancer
__________ Alcoholism
__________ Others
Please specify ___________________________________________________________________________
Surgical History:
Operation Date [ dd/mm/yy]
_______________________________________ ___________________
_______________________________________ ___________________
Family History:
Check the family members suffering from the disorder. [Mention about family diseases]
Medical Condition Mom Dad Sister Brother
_________________ ____ ____ ____ ____
__________________ ____ ____ ____ ____
Social History:
Smoker: ___________ [Yes / No] Rate: ____________ [out of 10]
Drinker: ___________ [Yes / No] Rate: ___________ [out of 10]