Example Medical Practice · General practice

Medical history form

Last tetanus shot, regular medication, allergies: with fak10, Anna fills in forms like this from what she knows about you. You see every entry first, and nothing goes out until you send it. What fak10 is · Apply for the beta

About you Full name Date of birth Health insurance Height, weight

Current symptoms What symptoms? Since when? How severe (1–10)?

Vaccinations Tetanus – last dose Flu – last dose Others

Medication and allergies Regular medication Allergies, intolerances

History Past illnesses, operations

Do you smoke?

no occasionally yes

Finish Date Name as signature

Good to know: practices usually ask about current symptoms, vaccinations, regular medication, allergies and past illnesses. Bringing your vaccination record and a list of your medication helps.

Medical history form

We've received your form.