Medical History Form

Prepare for your hospital stay by organizing your medical history and contact information. Download the printable PDF form to fill out and bring with you.

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What to Include in Your Medical History

Having this information organized and ready can help ensure you receive the best possible care.

Patient Information

Full Name

Date of Birth

Gender Identity

Phone Number

Email Address

Primary Care Physician & Advanced Directives

Physician Name

Phone Number

Advanced Directives (check all that apply)

Health Care Proxy HIPAA Release Power of Attorney DNR DNI MOLST

Medications

List all medications and supplements. Tip: Mark all medications prescribed by the same provider in one color.

Medication / Supplement	Dosage	Frequency	Purpose	Special Instructions

Current Treating Specialists

Specialty	Provider Name	Phone Number	Email

Medical Conditions and Diagnoses

Medical Condition / Treatment / Diagnosis	Year	Resolved or Ongoing

Allergies

List any known allergies, including drug, food, or environmental allergies.

Allergy	Reaction

Surgeries

Surgery	Reason	Year	Hospital

Health Insurance Information

Insurance Provider

Policy Number

Group Number

Primary Insurance Holder's Name

Primary Insurance Holder's Date of Birth

Contact Information for Daily Communication

List individuals you wish to be communicated with regarding your care. First contact will be primary contact.

Name	Relationship	Phone Number	Email Address	Preferred Contact

Remember to bring copies of:

ID Card
Insurance Card
Vaccination record
Advanced Directives
- Living Will
- Health Care Proxy Form
- DNR order

Download the printable PDF form to fill out by hand. For an editable version, contact us.