Medical History Form Template UK

The Medical History Form Template UK is offered in multiple formats, including PDF, Word, and Google Docs, featuring customizable and printable examples.

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Sample

Medical History Form Template UK

Editable – Printable

PDF – 1 PDF – 2

Medical History Form Template UK

1. Patient Information




2. Emergency Contact Information


3. Medical History

4. Current Medications

5. Allergies

6. Family Medical History

7. Lifestyle Information

8. Previous Medical Consultations

9. Consent

10. Additional Comments

11. Declaration and Signatures


PDF

WORD

Examples

Medical History Form Template UK (1)
Patient Information:
[Full Name]
[Date of Birth]
[Gender]
[Address]
[Phone Number]
[Email Address]
Emergency Contact:
[Contact Name]
[Relationship]
[Contact Number]
Medical History:
Please provide detailed information about your medical history, including:
  • Existing medical conditions (e.g., diabetes, hypertension)
  • Past surgeries and procedures
  • Family medical history (e.g., hereditary conditions)
  • Allergies (e.g., medications, food)
  • Current medications (include dosages and purposes)
  • Immunization history
Lifestyle Information:
Please answer the following questions:
  • Do you smoke? If yes, how many per day?
  • Do you consume alcohol? If yes, how often?
  • Do you exercise regularly? If yes, please specify the type and frequency.
  • Dietary preferences or restrictions:
Symptoms Review:
Please indicate if you have experienced any of the following symptoms in the past year:
  • Chest pain or discomfort
  • Shortness of breath
  • Unexplained weight loss
  • Fatigue that interferes with daily activities
  • Changes in vision or hearing
  • Persistent cough or blood in sputum
Consent:
I give my consent to [Name of the Medical Practice] to use this information for medical purposes and confirm that the information provided is accurate to the best of my knowledge.
Signed on [Date] in [City].
Sincerely,
[Signature of the Patient]
[Full Name of the Patient]
Medical History Form Template UK (2)
Patient Information:
[Full Name]
[Date of Birth]
[Gender]
[Address]
[Phone Number]
[Email Address]
Allergies:
Please list any known allergies and reactions to medications, food, or environmental factors:
Previous Medical Conditions:
List any significant past medical conditions or surgeries:
Family Medical History:
Please provide information about any family history of serious illnesses (e.g., heart disease, cancer, diabetes):
Current Medications:
List all medications you are currently taking, including over-the-counter drugs:
Review of Systems:
Please indicate if you have experienced any of the following symptoms:
  • Headaches
  • Stomach issues (nausea, vomiting, diarrhea)
  • Joint pain or swelling
  • Skin changes or rashes
  • Frequent infections or unusual bruising
Lifestyle Questions:
Please answer the following:
  • Do you participate in any sports or physical activities? If yes, please list:
  • What is your occupation and work environment?
  • Have you traveled outside the country in the past year? If yes, where?
Patient Declaration:
I declare that the information provided is complete and accurate. I understand that withholding information could affect my treatment.
Signed on [Date] in [City].
Sincerely,
[Signature of the Patient]
[Full Name of the Patient]

Printable

PDF – 1 PDF – 2

Medical History Form Template UK