Medical History Form Template

Medical history form template is a template of form that states a person’s medical report. It contains the histories of diseases the person might have encountered. It includes the person’s personal diseases, the health in general, and the specific factors that are possible to be relevant to current health in which it will show the assessment of a person’s health. It is gained after the person has performed medical examinations or some kinds of medical check up with a doctor. The medical record template usually has to provide these points:

  • Personal basic identities

It should provide a person’s name, weight, date of birth, height, age, etc.

  • CC or Chief Complaint

It contains the complaints that a person encounters.

  • HPI or History of the Person Illness

It provides the details of chief complaint. The person should write more specific complain about his diseases or his illness.

  • PMH or Past Medical History

It is a part that provides a summary that accumulate the person’s health from the past.

  • ROS or Review of System

It is a system review to indicate the systems of a person’s specific body. It is usually gained by a doctor after performing a particular physical examination.

  • Family diseases

It contains a person’s blood relatives’ diseases including grandparents, uncles, and aunts specifically those who have relevancy with the person’s diseases.

  • Childhood diseases

It is filled up by writing the diseases that the person has encountered when he was a child especially the diseases that is relevant to his current diseases.

  • SocHx or social history

It is about the aspects of occupation, familial address, and even recreation related to the person’s personal life in which it might influence the current health. It also contains how much the person approximately has consumed drugs, alcohol, tobacco, etc.

  • Acute and regular medications

It should be filled by the medications the person encountered including the medicine he consumed both acute and regular.

  • Allergies

It shows the person’s allergies on foods, medicine or medications, latex, and other factors in which emerging reactions such as: trouble breathing, irritation, swelling, and so on.

  • Sexual history

It provides the sexual history of the person in case it might be relevant for his current health.

  • Closure and conclusion

It contains the closure and conclusion of the points that a person has filled up above.

The medical history form template should be filled up accurately and truthfully by the person that requires it. The template of clinical record form mentioned above contains the points that hospital should provide for medical history inquiry. It is particularly the basic yet very important elements to emerge the records of personal health.

A medical history has a purpose to record a person’s health in the past and how it will probably be relevant to the recent health. The medical history form template helps to manage those medical records in a good way. For the hospital, it purposes to make their patients’ medical form in a clear inscription. Meanwhile, for the doctors, it aims to be understandable and so they can take care of their patients according to their medical histories in a proper way.