Free Medical History Checklist Template

Medical Chronicles Checklist

Name

Email

Address

Company

[your name]

[your email]

[your company address]

[your company name]

Individual's Health Record

  • Acute Illnesses (e.g., flu, infections)

  • Chronic Illnesses (e.g., diabetes, hypertension)

  • Surgeries and Hospitalizations (specify type and date)

  • Medications Currently Taken (list names and dosages)

  • Past Medical Conditions

Past Treatments and Outcomes

  • Diagnosed Conditions (specify diagnosis)

  • Details of Treatments (include therapy type and duration)

  • Outcome of Treatments (improved, unchanged, worsened)

Previous Medications and Procedures

  • Medications Taken in the Past (list names and dosages)

  • Medical Procedures Undergone (specify type and date)

Allergies

  • Food Allergies (specify allergens)

  • Medicinal Allergies (specify medications)

  • Environmental Allergies (specify allergens)

Family Health History

  • Parent's Health History (include major illnesses, if deceased cause and age)

  • Sibling's Health History (include major illnesses or conditions)

  • Grandparent's Health History (include major illnesses, if deceased cause and age)

Lifestyle Factors

  • Smoking History

  • Alcohol Consumption

  • Exercise Routine (frequency and type)

  • Dietary Habits (e.g., vegetarian, low carb)

Psychosocial History

  • Stress Levels (low, moderate, high)

  • Mental Health History (e.g., depression, anxiety)

  • Social Support System (family, friends, community)

Consent and Acknowledgement

  • Consent to Share Medical Information (with specified entities)

  • Acknowledgment of Information Accuracy

  • Please ensure all information is complete and accurate to the best of your knowledge.

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