Healthcare & wellbeing
Medical history
Longer than an intake form and built to be kept on file. Use it where a full history is genuinely needed; collecting health data you don't need is a liability in every jurisdiction.
- Questions
- 11
- Takes about
- 5 min
- Style
- One page
- Scoring
- None
Free, no card. It lands in your workspace as an editable draft.
Worth knowing
- The welcome screen and the intro text above the first question carry example turnaround times, policies and promises. Rewrite them as yours before you publish — they are the part respondents take literally.
What's in it
Your medical history
Welcome screen
Please read Answer as fully as you can; "none" is a useful answer, a blank is not · Includ…
Rich text
- 1
Full name*
Short text
- 2
Date of birth*
Date
- 3
Have you ever been diagnosed with any of these?
Asthma · Diabetes · Heart condition · High blood pressure · +2
Multiple choice
- 4
Any other conditions?
Long text
- 5
Previous operations, with rough dates
Long text
- 6
Current medication and dosage
Long text
- 7
Allergies and reactions
Long text
- 8
Do you smoke?
Never · Used to · Occasionally · Daily
Multiple choice
- 9
How often do you drink alcohol?
Never · Monthly or less · Weekly · Most days
Multiple choice
- 10
Anything significant in your family history?
Short text
- 11
Declaration*
Consent
Saved
Ending
How to use this template
Open it as a draft
Press "Use this template" and it lands in your workspace as an editable form with all 11 questions already in it. No card, and nothing is published until you say so.
Cut what you do not need
Every question you remove is one fewer reason to abandon the form. It takes about 5 minutes to fill in as it stands, and that is the number worth protecting.
Add from the question bank
Pick what you are missing from the questions below. Drag any of them in, change the wording, and use conditional logic so people only see the ones that apply to them.
Share it, or put it on your own site
Publish to get a link, or embed it in a page you already have. Answers arrive in your dashboard, and you can send them on to anywhere else with a webhook or an integration.
32 medical history form questions to choose from
A medical history form is long by necessity, which makes saving progress and working properly on a phone more important than anything cosmetic.
Every question here collects special-category data. Ask only what you will use, and set the retention period before the form goes live.
Current health
- Do you have any ongoing medical conditions?
- What medication are you currently taking, and at what dose?
- Do you take anything over the counter regularly?
- Do you take any supplements or herbal remedies?
- Do you have any allergies? What reaction do you get?
- Have you had any allergic reactions to medication?
- Are you pregnant, trying to conceive, or breastfeeding?
- Do you have any implants, pacemakers or prostheses?
Past medical history
- Have you had any surgery? What, and when?
- Have you been admitted to hospital in the last five years?
- Have you had any serious illnesses or injuries?
- Have you ever had a general anaesthetic?
- Did you have any problems with it?
- Have you had any blood transfusions?
- Which vaccinations have you had?
- Have you ever been treated for a mental health condition?
Family history
- Is there heart disease in your family?
- Is there diabetes?
- Is there any cancer? Which types?
- Is there high blood pressure or stroke?
- Are there any inherited conditions?
- Is there any mental health history you would like to share?
- Which relatives, and at what age were they diagnosed?
- Is there anything else in your family history we should know?
Lifestyle and consent
- Do you smoke or vape? How much, and for how long?
- How much alcohol do you drink in a typical week?
- Do you use any recreational drugs?
- How much exercise do you get?
- How would you describe your diet?
- What is your occupation?
- Do you consent to us contacting your GP?
- Do you confirm this information is accurate and complete?
Medical History form questions, answered
- What should a medical history form include?
- Current conditions and medication, allergies, relevant past history and family history. Ask what you will actually use at the appointment; a comprehensive form that nobody reads is cost without benefit.
- How should medical history data be protected?
- Responses are encrypted in transit and at rest and access is controlled by role, so only the people you choose can read them. The lawful basis and the retention period are yours to set, and no form supplies them for you.
- Can patients fill in a medical history over several sittings?
- Yes. Save and resume gives a private link back to the part-finished form, which matters on a form that needs medication names and dates from elsewhere in the house.
- How long should medical history records be kept?
- As long as your regulator requires and no longer. Set a retention period on the form and delete responses once they are in your clinical system.
- Is this medical history form template free?
- Yes. Use it, publish it and collect answers on the free plan with no card. Paid plans add things like payments, scheduling, removing our badge and your own domain, but none of them are needed to run this form.
- Do I need an account to use it?
- You need one to edit and publish, because the form has to live somewhere and the answers have to come back to you. Signing up takes about a minute and does not ask for a card. The people filling your form in never need an account.
- Can I change the questions?
- All of them. The template is a starting point, not a fixed form: add, remove, reword and reorder anything, change the look, and use logic so people only see the questions that apply to them.
- Can I put it on my own website?
- Yes. Embed it in a page you already have, or share the link. On a paid plan you can serve it from your own domain so the address says your name rather than ours.
- Where do the answers go?
- Into your dashboard, where you can read, search and export them as CSV. You can also have each response emailed to you, pushed to another tool with a webhook, or sent to a connected integration.
- How long does this form take to fill in?
- About 5 minutes as it stands, across 11 questions. Every question you cut brings that down, and shorter forms get finished more often.
Worth reading next
- What the rules actually ask of a small business formMost compliance advice is written for companies with legal departments. Here is the short version for a form that collects names and email addresses.
- The five accessibility fixes that matter most on a formNot a WCAG checklist. The handful of things that decide whether somebody using a screen reader or a keyboard can actually finish.