Clinical template
Medical History Template with Examples
The medical history is the standing record every SOAP, consult, and prescription depends on. In Canadian family practice it lives in the Cumulative Patient Profile (CPP). Build it once, keep it current, and stop pasting a 20-year narrative into every visit note.
Blank medical history (CPP)
Use this for a new patient, a hospital admission H&P, or a CPP rebuild. Date each major update. If a field is unknown, write unknown — do not leave a blank that looks like 'none'.
Medical history
Patient: [name, DOB, sex] | Date compiled / source: Preferred name / pronouns / language / interpreter: Family physician / pharmacy: Allergies / adverse reactions (drug, reaction, date if known): Alert conditions (e.g. anticoagulation, transplant, pacemaker, advanced directive): Past medical history (condition, year started, status, who follows): Past surgical / procedural history (procedure, year, hospital if known, sequela): Obstetric / gynecologic (G/P, deliveries, contraception, last Pap/mammogram as applicable): Mental health history (diagnoses, admissions, current follow-up): Medications: see medication list / BPMH — or summarize here if no separate list Immunizations (source: patient / provincial registry / record): Screening (FIT/colonoscopy, mammogram, cervical, AAA, etc. — date and result): Family history (relation, condition, age of onset/death): Social history Tobacco / vaping / cannabis: Alcohol (amount, AUDIT-C if used): Other substances: Occupation / exposures / shift work: Living situation / caregivers / safety: Function / mobility devices: Review of systems for new comprehensive visits only (pertinent):
Fictional patients
The worked example is made-up. A CPP is a legal part of the chart. If you generate history from an intake form or a conversation, the signing clinician still confirms allergies and anticoagulants before the next prescription.
What belongs in history vs the visit note
History is longitudinal. The visit note is today's story. Put 'T2DM since 2018, last A1c 7.4%, followed here' in the CPP. Put 'fasting glucoses 8–9 this week' in today's Subjective. When a diagnosis is new, add it to the CPP in the same sitting as the SOAP. When a drug is stopped, update both the medication list and the problem list if the indication died with it.
| Field | Good enough | Not good enough |
|---|---|---|
| Allergies | Ramipril — angioedema 2019; latex — contact rash | 'NKDA' when the hospital banner lists morphine nausea, or a blank field |
| PMHx | STEMI 2019, PCI to LAD, last echo 2024 EF 50%, cardiology Dr. Rao yearly | 'Heart problems' |
| Surgery | Lap chole 2016, no bile-duct injury; midline hernia repair 2021 with mesh | 'Abdominal surgery' with no year or approach |
| Family history | Father MI age 48; sister breast ca 41; mother T2DM | 'Family history positive' with no relation or age |
| Social | Smokes 8 cig/day, 20 pack-years; drinks 8–10 beer/week; lives alone, elevator building | 'Socially appropriate' or a copied sentence from 2014 |
Sources and contradictions
Patients forget surgeries. Provincial drug systems forget samples and OTCs. Hospital discharge letters forget the home puffer that never went on the MAR. When sources disagree, record both and say which you are acting on. For a new patient, the intake form is a draft. Confirm allergies, anticoagulants, and active cancer or transplant status yourself.
- Patient or SDM interview.
- Intake form and old records the patient brought.
- Discharge summaries and consult letters in the chart or provincial viewer.
- Pharmacy profile / PharmaNet, Netcare PIN, DSQ, or equivalent where you have access.
- Immunization registry when it exists in your province.
Example — new adult CPP
Family medicine, new patient
47-year-old woman, Mississauga. First visit, records from previous GP incomplete. Fictional.
Amina R., DOB 1979-01-22. Compiled 2026-08-26. Source: patient + old consult letter 2023 + pharmacy fax. Language: English. FP: this clinic (transfer). Pharmacy: Shoppers, Hurontario. Allergies: sulfa antibiotics — widespread rash 2008, no anaphylaxis. NKDA otherwise. No latex/food allergy known. Alerts: none. No anticoagulant. No advance directive on file — discussed, deferred. PMHx 1. Hypothyroidism — 2014, levothyroxine, last TSH 2025 'normal' per patient, no lab in chart — will repeat. 2. Migraine without aura — infrequent, sumatriptan PRN, neurology once 2019, no follow-up. 3. Iron deficiency 2023 — GI consult (Dr. Patel) gastroscopy/colonoscopy normal; on ferrous gluconate PRN; no recent ferritin. No diabetes, no HTN, no CAD, no asthma, no VTE, no cancer. PSHx: C-section 2012 (emergency, term). Wisdom teeth. No other OR. OB/GYN: G2P2 (2012 C/S, 2015 SVD). Contraception: LNG-IUS 2021, strings checked by previous GP. Last Pap 2024 NILM (patient report). Mammogram not yet started; will discuss at 50 or sooner if indicated. MH: mixed anxiety/depression 2020–2022, sertraline 18 months, stopped 2023, no admissions, no current SI. No current psychotropic. Meds: see BPMH (levothyroxine 112 mcg daily; sumatriptan 50 mg PRN; ferrous gluconate PRN; IUS in situ). Immunizations: COVID and influenza 2025 per patient; Tdap unknown — check registry. No pneumococcal. Screening: FIT never; Pap 2024 as above. FHx: mother T2DM age 55; father hypertension; maternal aunt breast ca age 62. No premature CAD, no CRC, no sudden death. Social Tobacco: never. Cannabis: none. Alcohol: 3–4 glasses wine/week. Other substances: none. Occupation: accountant, desk, no occupational toxins. Lives with spouse and two teens. Independent. Walks 30 min most days. Gaps to close this year: TSH, ferritin, immunization registry, FIT counselling, written allergy list to pharmacy.
Keeping the CPP honest
- Resolve 'history of asthma' vs active puffer use — status belongs on the line.
- Do not store six copies of the same surgical history in old SOAP notes as the source of truth.
- Pregnancy, new cancer, new anticoagulant, and new allergy are same-day CPP updates, not next-visit chores.
- Pediatric history needs birth weight, gestation, NICU, and developmental concerns in addition to the adult fields.
- If the patient declines to answer substance or safety questions, document the decline rather than inventing 'non-contributory'.
Pull history into the note, then keep the CPP current
Scribeberry can draft a structured history from the new-patient conversation or from dictation. You still update the EMR CPP and medication list. Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is included in a medical history?
Allergies, past medical and surgical history, medications (or a pointer to the med list), immunizations, screening, family history, and social history. Mental health, obstetric history, and alert conditions belong there too when they apply. The visit HPI is not a substitute for this standing record.
How is a CPP different from a SOAP note?
The CPP is cumulative: problems, meds, allergies, history. SOAP is one encounter. Canadian EMRs expect you to maintain both. Writing 'meds as per CPP' in SOAP is fine when the CPP is actually current.
What if the patient does not remember dates?
Record the decade or 'year unknown' and the source. Request old records. Do not invent a year to make the template look complete. Flag items you still need (TSH, operative report, immunization registry).
Can Scribeberry build a medical history from the intake visit?
Yes. Record or dictate the new-patient visit with a history template. Review allergies and medications before the CPP is saved. Custom templates can match your EMR's CPP field order.
Templates
