Medical history form: get the background before the visit

Nobody remembers a surgery date at a front desk. I would rather give patients a link they can open at home, next to the medicine box. The answers arrive as rows you can read before the patient walks in.

Who should use it

Small clinics, dentists, physios and specialists who want the background in hand. It also suits a practice that moves to a new system and needs fresh histories.

What the questions are for

Conditions, other conditions and surgeries: the past that shapes today's care.
Medicines and supplements: what the patient takes right now.
Allergies and reactions: the reaction matters as much as the allergy.
Family history: a quick list of what runs in the family.
Smoking, alcohol, exercise: habits, asked plainly and without judgment.
Confirmation box: the patient says the answers are right as far as they know.

What a patient's AI would ask

"Have you ever had surgery or a hospital stay?" Then "Which medicines do you take?" Then "Has anyone in your close family had heart disease?" It shows the answers and sends only after a yes. See agent-fillable forms.

Before you use it

Check your local privacy rules before collecting health data. This is a form, not medical advice. Insurance and ID numbers are left out on purpose. Pair it with a medical records request form and a referral form. More ideas are in forms for clinics.

Questions

Is this the same as an intake form?

Not quite. Intake collects contact details and the reason for a visit. This form goes deeper into the past: conditions, operations, medicines and family background. Many clinics send both.

What if a patient does not remember a date?

The form says it is fine to write that they do not know. Most answers are free text, so a patient can write about two years ago instead of an exact date.

Can a patient get help from their AI?

Yes. A patient can paste the agent prompt into their own chat. The AI asks about each topic, lists all answers and submits only after the patient says yes.

Or paste the JSON

Give this to your AI. It needs the AI Form API MCP server or an API key. It makes the form and sends you the link.

text

Create this form with the AI Form API create_form tool (or POST https://aiformapi.com/v1/forms with my API key). Then reply with the public_url.

{
  "title": "Your health history",
  "description": "Please fill this in before your visit. Answer as well as you can. It is fine to write that you do not know.",
  "fields": [
    {
      "id": "patient_name",
      "label": "Your full name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "date_of_birth",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "main_concern",
      "label": "What is the main reason for your visit?",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "past_conditions",
      "label": "Conditions you have or have had",
      "type": "multi_choice",
      "options": [
        "High blood pressure",
        "Diabetes",
        "Asthma or breathing problems",
        "Heart condition",
        "Thyroid condition",
        "Cancer",
        "Depression or anxiety",
        "Arthritis",
        "Stroke",
        "None of these"
      ]
    },
    {
      "id": "other_conditions",
      "label": "Any other conditions",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "surgeries_hospital",
      "label": "Surgeries and hospital stays",
      "type": "long_text",
      "help": "Add the year if you remember it.",
      "max_length": 1000
    },
    {
      "id": "regular_medicines",
      "label": "Medicines and supplements you take",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "allergy_reactions",
      "label": "Allergies and what happens when you react",
      "type": "long_text",
      "max_length": 800
    },
    {
      "id": "family_history",
      "label": "Conditions in your close family",
      "type": "multi_choice",
      "options": [
        "Heart disease",
        "Diabetes",
        "Cancer",
        "High blood pressure",
        "Stroke",
        "Mental health conditions",
        "None that I know of"
      ]
    },
    {
      "id": "smoking_status",
      "label": "Do you smoke or vape?",
      "type": "single_choice",
      "options": [
        "Never",
        "I used to",
        "Sometimes",
        "Every day"
      ]
    },
    {
      "id": "alcohol_use",
      "label": "How often do you drink alcohol?",
      "type": "single_choice",
      "options": [
        "Never",
        "A few times a year",
        "Weekly",
        "Most days"
      ]
    },
    {
      "id": "exercise_days",
      "label": "On how many days a week do you exercise?",
      "type": "number",
      "min": 0,
      "max": 7
    },
    {
      "id": "history_confirm",
      "label": "My answers are correct as far as I know",
      "type": "checkbox",
      "required": true
    }
  ]
}

Or call the API

bash

curl -X POST https://aiformapi.com/v1/forms \
  -H "Authorization: Bearer $AIFORMAPI_KEY" \
  -H "Content-Type: application/json" \
  -d '{"title":"Your health history","description":"Please fill this in before your visit. Answer as well as you can. It is fine to write that you do not know.","fields":[{"id":"patient_name","label":"Your full name","type":"short_text","required":true,"max_length":150},{"id":"date_of_birth","label":"Date of birth","type":"date","required":true},{"id":"main_concern","label":"What is the main reason for your visit?","type":"long_text","max_length":1000},{"id":"past_conditions","label":"Conditions you have or have had","type":"multi_choice","options":["High blood pressure","Diabetes","Asthma or breathing problems","Heart condition","Thyroid condition","Cancer","Depression or anxiety","Arthritis","Stroke","None of these"]},{"id":"other_conditions","label":"Any other conditions","type":"long_text","max_length":1000},{"id":"surgeries_hospital","label":"Surgeries and hospital stays","type":"long_text","help":"Add the year if you remember it.","max_length":1000},{"id":"regular_medicines","label":"Medicines and supplements you take","type":"long_text","max_length":1000},{"id":"allergy_reactions","label":"Allergies and what happens when you react","type":"long_text","max_length":800},{"id":"family_history","label":"Conditions in your close family","type":"multi_choice","options":["Heart disease","Diabetes","Cancer","High blood pressure","Stroke","Mental health conditions","None that I know of"]},{"id":"smoking_status","label":"Do you smoke or vape?","type":"single_choice","options":["Never","I used to","Sometimes","Every day"]},{"id":"alcohol_use","label":"How often do you drink alcohol?","type":"single_choice","options":["Never","A few times a year","Weekly","Most days"]},{"id":"exercise_days","label":"On how many days a week do you exercise?","type":"number","min":0,"max":7},{"id":"history_confirm","label":"My answers are correct as far as I know","type":"checkbox","required":true}]}'

JSON definition

json

{
  "title": "Your health history",
  "description": "Please fill this in before your visit. Answer as well as you can. It is fine to write that you do not know.",
  "fields": [
    {
      "id": "patient_name",
      "label": "Your full name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "date_of_birth",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "main_concern",
      "label": "What is the main reason for your visit?",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "past_conditions",
      "label": "Conditions you have or have had",
      "type": "multi_choice",
      "options": [
        "High blood pressure",
        "Diabetes",
        "Asthma or breathing problems",
        "Heart condition",
        "Thyroid condition",
        "Cancer",
        "Depression or anxiety",
        "Arthritis",
        "Stroke",
        "None of these"
      ]
    },
    {
      "id": "other_conditions",
      "label": "Any other conditions",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "surgeries_hospital",
      "label": "Surgeries and hospital stays",
      "type": "long_text",
      "help": "Add the year if you remember it.",
      "max_length": 1000
    },
    {
      "id": "regular_medicines",
      "label": "Medicines and supplements you take",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "allergy_reactions",
      "label": "Allergies and what happens when you react",
      "type": "long_text",
      "max_length": 800
    },
    {
      "id": "family_history",
      "label": "Conditions in your close family",
      "type": "multi_choice",
      "options": [
        "Heart disease",
        "Diabetes",
        "Cancer",
        "High blood pressure",
        "Stroke",
        "Mental health conditions",
        "None that I know of"
      ]
    },
    {
      "id": "smoking_status",
      "label": "Do you smoke or vape?",
      "type": "single_choice",
      "options": [
        "Never",
        "I used to",
        "Sometimes",
        "Every day"
      ]
    },
    {
      "id": "alcohol_use",
      "label": "How often do you drink alcohol?",
      "type": "single_choice",
      "options": [
        "Never",
        "A few times a year",
        "Weekly",
        "Most days"
      ]
    },
    {
      "id": "exercise_days",
      "label": "On how many days a week do you exercise?",
      "type": "number",
      "min": 0,
      "max": 7
    },
    {
      "id": "history_confirm",
      "label": "My answers are correct as far as I know",
      "type": "checkbox",
      "required": true
    }
  ]
}

A medical history form for the first appointment