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Past Hospitalization Record Form

Asks about inpatient hospitalizations, admission & discharge dates, and discharge diagnoses. Built for primary care new patient intake with significant hospital history.

Questions
10
Page
1
Time
about 3 min

Includes

  • E-signature
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Your practice

Past Hospitalization Record Form

Live preview. Tap through it like a patient.

Who it is for

  • 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

What's inside

  1. Full NameText · Required
  2. Inpatient HospitalizationsLong Text
  3. Admission & Discharge DatesDate
  4. Discharge DiagnosesLong Text
  5. Procedures During HospitalizationLong Text
  6. ICU Admission HistoryLong Text
  7. Emergency Department VisitsLong Text
  8. Post-Discharge ComplicationsLong Text
  9. 30-Day Readmission HistoryLong Text
  10. Patient SignatureE-Signature

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Past Hospitalization Record Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

Related templates

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 10 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Past Hospitalization Record Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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