HIPAA Medical History Form Template
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HIPAA Medical History Form
Please complete this form to provide your medical history.
Name
Date of Birth
Home Address
Contact Number
Do you have any chronic medical conditions?
If yes, please specify:
Are you currently taking any medications?
If yes, list all medications:
Do you have a history of surgeries or hospitalizations?
If yes, please provide details:
Have you experienced any of the following?
Check all that apply:
Heart Disease
Diabetes
High Blood Pressure
Asthma
List any known allergies:
List any medications you are allergic:
By signing below, I acknowledge that the information provided is accurate to the best of my knowledge. I understand that this information will be used for my care and will be protected in compliance with HIPAA regulations.
Name:
Date:
Thank you for your submission!
We appreciate you taking the time to submit.
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