Permanent history form 2025

See details

4.5 out of 5

45 votes

The document is a confidential medical history form that collects personal health information from a patient, including past and current medical conditions, allergies, medications, and emergency contact details. It requires the patient's acknowledgment of the accuracy of the provided information and informs them about the necessity of a doctor's release for certain medical procedures.

Here's how it works

01. Edit your makeup medical form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out the permanent history form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the permanent history form in the editor.
Begin by entering your name and birth date in the designated fields at the top of the form. This information is crucial for identifying your medical history.
Indicate whether you have been under a physician's care in the last two years by selecting 'Yes' or 'No.' If 'Yes,' provide your physician’s name, address, and phone number in the space provided.
Fill out the emergency contact section with a name, address, and phone number. This ensures that someone can be reached if necessary.
For each listed medical condition and procedure, mark 'Y' for yes or 'N' for no. Be thorough to ensure accurate medical assessment.
List any additional diseases not mentioned above in the provided space to give a complete picture of your health.
Complete the allergy section by marking any drugs you are allergic to with 'Y' or 'N.'
Finally, review all entered information for accuracy before signing at the bottom of the form to acknowledge its correctness.

Start filling out your permanent history form today on our platform for free!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the fastest way to get medical records?

If your provider has a designated medical records department, contact them directly. Provide any reference numbers, confirmations, or details you received when submitting your request. It will help your provider quickly locate your file.

What is a history form?

Medical history forms that collect comprehensive medical profiles are a critical part of patient care. It provides the full picture of a patients health so you can understand their medical background, family medical history, potential risk factors, and current health status thoroughly.

How do you get a medical history?

Ask for the information you need the way you need it like part or all of your record, a paper or electronic record, and the number of copies you need. Request a copy of your health record from your provider including how to fill out a form asking for your record.

How do you get a medical history form?

How you make your request will depend on your providers processes. You may be able to request your record through your providers patient portal. You may have to fill out a form called a health or medical record release form, or request for accesssend an email, or mail or fax a letter to your provider.

What are examples of a patients history?

Please list any past medical history below with date of onset or diagnosis. Examples include asthma, diabetes, depression, anxiety, drug or alcohol dependency, high blood pressure, thyroid disease, autoimmune disease, chronic pain, gynecologic disorder. Have you ever had surgery?

How to fill up a personal history form?

How to Fill in Personal History Form Gather Necessary Information. Complete Personal Information. Detail Your Education. Outline Your Professional Experience. Describe Your Language Skills. Include Additional Skills. Add References. Review and Attach Supporting Documents.

Permanent history form 2025

Here's how it works