Medical History Form
The Medical History Form Template is a powerful and easy-to-use tool designed for clinics, hospitals, private practices, and telehealth providers. It allows healthcare professionals to digitally collect, organize, and maintain comprehensive medical records of patients — all in one place. Whether it’s new patient onboarding or routine updates, this form streamlines data collection and helps ensure accurate, timely, and secure documentation of a patient’s health background.
Key Form Fields and Tables
1. Patient Information
This section collects the basic demographics and identifiers necessary to associate each medical record with the right patient. Key fields include:
Full Name
Date of Birth
Gender
Contact Number
Email Address
Emergency Contact
2. Medical History
Capture a complete history of previous and existing medical conditions. This table helps provide context for diagnosis and treatment plans. Fields include:
Past Illnesses (e.g., diabetes, hypertension, asthma)
Surgeries or Hospitalizations
Family Medical History (e.g., heart disease, cancer)
Current Medications
Ongoing Treatments
3. Allergies and Reactions
Crucial for treatment safety, this section tracks any known allergies to medications, food, or environmental factors. Key fields:
Type of Allergy (Drug, Food, Environmental)
Allergen Name
Reaction Severity (Mild, Moderate, Severe)
Notes or Emergency Instructions
4. Lifestyle & Habits
A patient’s lifestyle often plays a critical role in healthcare. This table includes:
Smoking and Alcohol Use
Dietary Restrictions
Exercise Frequency
Sleep Patterns
Mental Health History
5. Insurance & Consent
Enable patients to provide their insurance details and sign off on information usage and treatment consent. Fields include:
Insurance Provider
Policy Number
Primary Holder
Consent Checkbox for Treatment and Data Use
Digital Signature Field
Top Features
Fully Customizable: Add or remove questions, create dropdowns, checkboxes, or attach documents based on your clinic’s specific needs.
Digital and Paperless: No more paper forms — collect everything securely online with Stackby’s embedded form sharing.
Linkable Records: Automatically connect data across related tables such as medications, treatments, and visits.
Auto Timestamping: Capture form submission dates automatically for better recordkeeping.
HIPAA-Ready Structure: While Stackby doesn’t provide HIPAA compliance out of the box, this template follows best practices for health data capture.
Export and Share: Easily export records in CSV or PDF formats or share summaries with specialists.
Use Cases
Clinics and Primary Care Facilities: Streamline the patient intake process by capturing full health histories before appointments.
Telehealth Providers: Digitally collect medical information before virtual visits.
Specialist Practices: Gather condition-specific histories like allergies, orthopedic injuries, or cardiology concerns.
Health Camps and Pop-Ups: Quickly onboard multiple patients during short-term healthcare initiatives.
Home Health Services: Use this form to gather vital information for remote care programs.
Why Use the Medical History Form Template?
Accuracy and accessibility of medical history data are critical to delivering quality healthcare. Manual data collection methods often lead to errors, missing records, or time-consuming paperwork.
This Medical History Form Template eliminates that friction. By digitizing your patient intake and record management process, you ensure every provider has timely access to essential background data — improving clinical decision-making, reducing duplication, and enhancing the overall patient experience.
Whether you're an independent practitioner, a multi-location clinic, or part of a growing telehealth service, this template can adapt to your workflow — while keeping everything organized in one collaborative workspace.
