Medical History Form
A medical history form is a document that briefs a doctor and enables him to understand the health history of his/her patient. Apart from patients’ health history information, the document is also of importance to insurance companies in their quest to determine insurability of a person’s medical cover.
Sample Medical History Form
Applicant Name: ___________________________________Date of Birth __________
Date ___________________________
(Answer the statements below on the spaces provided)
Are you a smoker? _______
Frequency of smoking ________
Number of years you have smoked ____________
Do you consume alcohol ___________
List the medicines you are using:
______________________________ ________________________________ __
Known allergies and causes:
Are you receiving any medical care? If so, elaborate:
_______________________________________________________________________
Have you ever been operated on? If yes, please explain (giving details of doctors, hospitals and dates of where you were operated on
_______________________________________________________________________
List the conditions that any of your relatives maybe suffering on_____________________
If you experience side effects from the medication you are using please notify us immediately.
___________________________________________
________________________ Signature Date
Category: Medical Forms
