Patient registration and medical history form

A one-page form for the waiting room: the patient's details, a yes/no medical history, allergies, current medicines and a signature. There's a general version and a dental version with a few questions about teeth and gums. Add your clinic's name at the top, then print a stack or save it as a PDF.

Updated 16 October 2026

Your clinic (printed at the top)

Clinic nameAddressPhone

Form for

To get a PDF, choose Save as PDF as the printer. What you type stays in this browser; it isn't sent to us.

Clinic name

Patient registration

and medical history

Your details

Full name

Father's / husband's name

Age or date of birth

GenderMaleFemaleOther

CNIC

Occupation

Phone 1

Phone 2

Address

Referred by

Health insurance and number

Emergency contact (name and phone)

Medical history: do you have, or have you had

DiabetesYesNo

High blood pressureYesNo

Heart disease or a heart operationYesNo

Asthma or other breathing problemsYesNo

Hepatitis B or CYesNo

Bleeding problems or easy bruisingYesNo

Kidney diseaseYesNo

Thyroid problemsYesNo

Epilepsy or fitsYesNo

Pregnant or breastfeedingYesNo

Any operation in the last yearYesNo

Any other long-term illnessYesNo

Allergies (medicines such as penicillin, latex, foods)

Medicines you take now (include blood thinners such as aspirin or warfarin)

Do you smoke, or use naswar, gutka or paan?YesNo

Do you drink alcohol?YesNo

What brings you in today?

The information above is correct to the best of my knowledge. I will tell the clinic if my health or my medicines change.

Signature

Date

For clinic use: entered in records by ________ on ________

What's on the form, and why

Details: name, father's or husband's name, age or date of birth, gender, CNIC, two phone numbers, email, address, occupation, who referred them, health insurance, and an emergency contact. Apart from the emergency contact, these are the fields of the New Patient form in FindClinica, so the receptionist can copy a filled form straight into the app.

Medical history: diabetes, blood pressure, heart disease, asthma, hepatitis B or C, bleeding problems, kidney and thyroid disease, epilepsy, pregnancy or breastfeeding, and recent operations. Allergies and current medicines get their own lines, with blood thinners called out, because those change what you can safely do.

Smoking, naswar, gutka or paan: worth asking in every clinic here, and especially before any dental work.

Using it well

Hand it over with a clipboard and pen when the patient checks in, and look through it before you start. Ask again at every follow-up whether anything has changed, especially medicines. Keep the signed form in the patient's file; if your healthcare commission inspects patient records, a signed history is the kind of thing that helps.

This isn't a consent form. Consent for a procedure needs its own form, explained to the patient, for that specific treatment.

From paper into the patient's file

In FindClinica the same details go into the patient's file once, and the systemic history and allergies you note are filled in again on the prescription screen and go on printed records. Search finds the patient later by name or phone number. How the patient record works.

New Patient form in FindClinica with name, age, gender, contact, CNIC and father's name — FindClinica dentist & medical software — The New Patient form in FindClinica has the same fields.

Common questions

Is there an Urdu version?

Not yet. The form is in English; many clinics have the receptionist help patients who prefer Urdu fill it in.

Can I add my own questions?

Not on this page. If you need a custom form, save the PDF and add lines by hand, or ask us on WhatsApp what you'd like to see.

Is it a consent form?

No. It records the patient's details and history and their confirmation that it's correct. Consent for a procedure needs a separate form.

Type it in once, find it in seconds

FindClinica keeps every patient's details, history and allergies on one file. Free plan, unlimited patients.

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