Past Hospitalization Record Form
Form Preview
Past Hospitalization Record Form
Page 1 of 1
Sign up and start customizing in minutes.
Start with the Past Hospitalization Record Form template and tailor it to your practice. It includes 10 editable fields across 1 page. Included questions: Full Name, Inpatient Hospitalizations, Admission & Discharge Dates, Discharge Diagnoses. The full field list below shows what you will get when you add this template to your account.
Choose this template to open an editable form. Review the questions, keep only the information your practice needs, and add your branding. Preview the patient experience before sharing a link or embedding the form. Responses can be reviewed in Formisoft and exported as a PDF.
What's included
- Full Name
- Inpatient Hospitalizations
- Admission & Discharge Dates
- Discharge Diagnoses
- Procedures During Hospitalization
- ICU Admission History
- Emergency Department Visits
- Post-Discharge Complications
- 30-Day Readmission History
- Patient Signature
Who uses this template
- Primary care new patient intake with significant hospital history
- Care coordination and transitional care management programs
- Hospitalist service admission history documentation
- Risk stratification for readmission prevention programs
All form fields
10 fields across 1 page. Customize any field after signing up.
How to use the Past Hospitalization Record Form
Getting started with this template takes just a few minutes. Sign up for a Formisoft trial, then select the Past Hospitalization Record Form from the template library. Review the included questions, customize your fields, and preview the form before sharing it.
Setup steps
- 1Choose the template. Find the Past Hospitalization Record Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 10 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
How does Formisoft protect responses?
Formisoft provides secure form collection and a Business Associate Agreement (BAA). Your practice must review the form content, access permissions, and sharing workflow for its requirements.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 10 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
With a plan that includes automation, you can configure workflows to send forms and reminders. Appointment-based sending requires the booking event to reach Formisoft.
Does this template work on mobile devices?
Yes. The Past Hospitalization Record Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Past Hospitalization Record Form for your practice. Set up in minutes.
Related templates
Discharge Survey
Customize the Discharge Survey template for your practice. 12 editable fields, including Patient Name, Discharge Date, Discharge Instruction Clarity, Medication Understanding.
Post-Operative Assessment Form
Customize the Post-Operative Assessment template for your practice. 14 editable fields, including Full Name, Procedure Performed, Surgery Date, Pain Level (0-10 Scale).
Stroke Assessment (NIH Stroke Scale)
Customize the Stroke Assessment (NIH Stroke Scale) template for your practice. 17 editable fields, including Full Name, Symptom Onset / Last Known Well, Level of Consciousness, LOC Questions (Orientation).
