# Medical History Form Template > Medical History Form template for WordPress with 8 fields. One-click install with FormForge Pro plugin. Comprehensive medical history questionnaire. - Canonical: - Last updated: 2026-03-15 - HTML version: --- Agency 8 fields Industry-Specific Comprehensive medical history questionnaire. Full Name \* Date of Birth \* Blood Type Select...A+A-B+B-O+O-AB+AB-Unknown Past Surgeries Family Medical History Cancer Heart Disease Diabetes Mental Health Conditions None known Current Medications & Dosage Smoking Status Never smoked Former smoker Current smoker Exercise Frequency Daily 2-3 times/week Rarely Never ## Form Fields | Field | Type | Required | | --- | --- | --- | | Full Name | Text | Required | | Date of Birth | Date | Required | | Blood Type | Select | Optional | | Past Surgeries | Textarea | Optional | | Family Medical History | Checkbox | Optional | | Current Medications & Dosage | Textarea | Optional | | Smoking Status | Radio | Optional | | Exercise Frequency | Radio | Optional | ## What’s Included with Agency Everything in Business, plus: Industry-Specific Templates White-Label Branding Priority Support Unlimited Sites Client Management Tools Custom Integrations 1 Year Updates & Support ## Related Templates Full Name \* Email Address \* Phone Number \* Training Goals Weight Loss Strength Training Sports Performance Injury Rehabilitation General Fitness Availability Mornings (6am–9am) Midday (11am–1pm) Afternoons (3pm–5pm) Evenings (6pm–8pm) Weekends Budget Per Session Select...Under $50$50 – $75$75 – $100Over $100 Training Experience Never had a trainer Some experience Experienced Trainer Gender Preference Male Female No Preference Additional Notes Agency 9 fields ### Personal Training Request Request a personal trainer match. [View Template](https://royalplugins.com/formforge/templates/personal-training/) Patient Name \* Date of Birth \* Phone Number \* Medication Name \* Dosage / Strength \* Preferred Pharmacy Prescribing Doctor Additional Notes Agency 8 fields ### Prescription Refill Request Request medication refills online. [View Template](https://royalplugins.com/formforge/templates/prescription-refill/) Company Name \* Contact Name \* Email Address \* Project Type \*Select...New WebsiteWebsite RedesignWeb / Mobile AppMarketing CampaignBranding ProjectOther Target Deadline Budget Range Select...Under $5,000$5,000 – $15,000$15,000 – $50,000Over $50,000 Project Objectives \* Target Audience Specific Requirements Examples / Inspiration (URLs) Supporting Files Click or drag to upload Agency 11 fields ### Project Brief Client project brief submission form. [View Template](https://royalplugins.com/formforge/templates/project-brief/) ## Use This Template Get FormForge Agency and start building with the Medical History Form template today. [Get FormForge Agency](https://my.royalplugins.com/checkout/?add-to-cart=248)