Health History Form

Our Health Order Form template makes it easy to collect health-related information from patients or clients. This customizable form allows you to gather details such as medical history, symptoms, and current medications.

Use this free template to simplify your health order process and provide better care for your patients or clients.

Customize in minutes

Drag and drop 40+ customizable question types to make this template your own.

Scheduling

Calendly, Chili Piper, cal.com

Social security input

Securely collect PII

E-signatures

Legally binding signatures

Mailing addess input

Autocomplete with the Google Maps API

Collect phone numbers

Domestic or international

Captcha

Verify human respondents

+ dozens more

Connect to
Notion

Send responses wherever you need them, in 60 seconds:

1Clone this template.

2Connect your integration in Fillout.

3Share a link or embed forms anywhere ⚡️

Template FAQs

Why should I use a Health History Form online?: Having a Health History Form online can save you time and ensure that all necessary health information is captured accurately. In addition, online forms can be securely stored and accessed from anywhere, making it easier to keep track of your health history and share it with healthcare professionals when needed. With Fillout’s Health History Form template, you can easily create a professional-looking form that includes all the necessary questions and helps you organize your health history in one place.
What type of information should I include in my Health History Form?: Your Health History Form should include basic information such as your name, date of birth, and contact details. It should also include information about your medical history, including any existing conditions, surgeries, allergies, medications, and family history of medical conditions. This information will help your healthcare provider make an accurate diagnosis and develop an appropriate treatment plan. The Health History Form template provided by Fillout includes all the necessary sections and questions to help you capture this information accurately and efficiently.
Can I customize my Health History Form?: Yes, you can customize your Health History Form to include any additional questions or sections that are relevant to your particular health history. You can also customize the look and feel of the form to match your personal preferences or branding. Fillout’s Health History Form template includes a wide range of customization options, including the ability to add your own logo, change colors and fonts, and include additional fields.
Is my Health History Form secure?: Yes, your Health History Form is secure when created using Fillout’s platform. Fillout uses SSL encryption to protect your data and follows industry best practices to ensure that your information is stored securely. In addition, you can password-protect your form to ensure that only authorized individuals can access it.