Free to start. Yours to shape.
Health history form template
Learn a new patient’s or client’s health history before the first appointment. A free health history form for patient intake, with the main concern, current conditions, medication, allergies and past surgeries, and a consent line at the end.
No account needed to edit. Create a free account to publish.
Fonts and colors on every plan. Your logo and no trulyform badge: Business only.
Inside the template · 12 questions
What’s in this health history form template?
The form opens with a full name, date of birth, the best phone number and an optional email. Then the person describes what brings them in, in their own words, and ticks any conditions that apply, from high blood pressure and diabetes to a thyroid condition or anxiety.
Medication and allergies are yes-or-no questions. A follow-up about which medications and how often, or what they are allergic to, appears only after a “Yes”; that logic is already set up. An optional question covers surgeries and hospital stays, and the form ends with a required consent line. The name, date of birth, phone number, main concern, both yes-or-no questions and the consent are required.
Edit the wording, add or remove questions, and change the look in the editor.
Use this template-
1
What is your full name?
-
2
What is your date of birth?
-
3
What is the best number to reach you?
-
4
What is your email?
-
5
What brings you in?
-
6
Do you have any of these conditions?
High blood pressure · Diabetes · Heart condition · Asthma or breathing problems · Thyroid condition · Anxiety or depression · None of these
-
7
Are you taking any medication?
Yes · No
-
8
Which medications, and how often?
Asked after “Yes”
-
9
Do you have any allergies?
Yes · No
-
10
What are you allergic to?
Asked after “Yes”
-
11
Have you had any surgeries or hospital stays?
-
12
I confirm this information is accurate and agree to it being kept for my care.
Before the first appointment
Practices this health history form suits
Nutritionists, physiotherapists, psychologists, dentists, massage therapists, personal trainers and aesthetics clinics all begin with much the same questions. Send the form when the appointment is booked, and read the answers before the person arrives.
The first session can start with the conversation instead of the paperwork. Each completed form lands in your trulyform inbox, and you can export the answers as a CSV file at any time.
Ways to adapt it to your practice
- For nutritionists: add questions about eating habits, how much water the person drinks and any foods they avoid. A goal question with a few choices helps you prepare for the first session.
- For physiotherapists and trainers: ask whether the person has pain or an injury. With logic, show where it hurts and how long it has lasted only to people who answer “Yes”.
- For psychologists and therapists: replace the conditions list with questions about what the person would like to work on and whether they have had therapy before.
- For test results or referrals: add a file upload question so people can attach a recent report before the appointment.
Make these changes in the editor. The twelve starter questions are listed above. File uploads need an account and count toward your plan’s storage allowance. Ask only what you will use.
From template to the first appointment
-
01
Make it fit your practice
Put your name or your clinic’s name in the welcome message. Adjust the questions, colors and fonts, then preview the form, including the follow-ups that appear after a “Yes”.
-
02
Publish your form
Choose Publish, then sign up with Google or email. Everything you changed comes with you.
-
03
Send it when you book
Share the link with your booking confirmation, by email or by text. Read the answers in your inbox before the appointment.
Good questions
A few things you might wonder.
Still curious? Send us a note or email support@trulyform.com.
Planning how many responses you’ll collect? See Free plan limits.
What should a health history form include?
Contact details, the reason for the visit, current conditions, medication, allergies and past surgeries or hospital stays cover the basics for most practices. Add questions about habits, family history or previous treatment only when the answers change how you prepare.
Is this health history form template free?
Yes. You can edit it without an account. Create a free trulyform account to publish it and collect responses within the Free plan’s monthly allowance.
Can I use it as a patient intake form or a medical history form?
Yes. Its twelve questions cover what most patient intake and medical history forms ask first. Rename the form, change the welcome message and add the questions your field needs.
Does everyone see the medication and allergy follow-ups?
No. Someone who answers “No” goes straight on to the next question. A “Yes” opens a follow-up about which medications they take and how often, or what they are allergic to. The logic is already set up, and you can change it in the editor.
How should I handle the health information I collect?
Health information is sensitive, so ask only what you need for the appointment. The template ends with a required consent line: the person confirms their answers are accurate and agrees to them being kept for their care. trulyform is a form builder, not a medical records system. Answers arrive in your trulyform inbox, and you are responsible for how you store and use them under the rules of your profession.
How do I send the form to a patient or client?
When you publish, a “Share your form” window opens. Copy the public link for a booking confirmation, an email or a text, or paste the code under “Embed on your website” into your practice’s website. trulyform does not email your patients, so send the link yourself.
Will I know when someone has filled it in?
The organization owner gets an email after the first completed response. Later completions are grouped into summaries, sent at most once an hour. Every completed form stays in your response inbox and can be exported as CSV.
Can I remove the trulyform logo from a template?
Not on Free or Pro. Business adds your logo and removes our badge. Colors and fonts are yours on every plan.