Medical history form template

Questions in this form

• Page: About you
• Full name required
• Date of birth required
• Phone
• Email required
• Page: Medical history
• Have you ever had any of these?
• Have you had any surgeries or hospital stays?
• Please list them with approximate dates required shown only when needed
• Current medications and doses
• Do you have any allergies? required
• What are you allergic to, and what happens? required shown only when needed
• Family history
• Page: Lifestyle
• Do you smoke? required
• How often do you drink alcohol?
• How often do you exercise?
• Anything else your doctor should know?
• Agreement required
• Signature required

Smart logic

2 questions appear only when an earlier answer makes them relevant, so people never see questions that do not apply to them.

The document it creates

Every response becomes a ready made medical history document laid out in the Minimal design, as a PDF or Word file. It is saved to your Drive in a folder for this form and attached to the respondent's copy of their answers. With Pro you can switch to your own Word or PDF template.

How to use it

1. Use the template. It opens in the form builder with the Soft theme already applied.
2. Make it yours. Change questions, logic, colours and fonts. The live preview shows exactly what respondents will see.
3. Publish and share. Copy the link, embed the form on your website or download its QR code. Responses arrive in a table with charts and exports.