A DOH (department of health) health record template is a prewritten document which acts as a health record template for many hospitals or individuals to keep a record of their medical history. There can be various different types of DOH Health record templates which one can be used as per their needs and requirements. The DOH health record template is one document which helps health institutes to get a proper health record form which has a well detailed and outlined structure and the right composition of the content. The users just need to modify the template to suit their specifications and needs. The fact that these templates can be customised makes them very popular and thus widely used by a lot of people.  Given below is a sample of a DOH health record template.

“You can Download the Free DOH Health Record Template form, customize it according to your needs and Print. DOH Health Record Template is either in MS Word, Excel or in PDF.”

Sample DOH health record template

DOH health record template

Download DOH health record template

Name: _________ [mention the name of the person whose health record is being made]

Sex: __________ [male/female]

Age: __________ [write the age]

Date of birth: ________ [dd/mm/yy]

Starting date of health record: _______ [dd/mm/yy]

Termination date of health record: ____________ [dd/mm/yy]

Details of List of appointments:

Date                          physician/phone number                               reason for visit

[Make a list of all appointments with all the doctor’s visited during the health record period]

Details of Personal habits:

Do you do the following, answer in yes or no:

Drink alcohol: ________ [yes/no]

Currently smoke: _______ [yes/no]

Exercise: _______ [yes/no]

Take any sleeping pills: _______ [yes/no]

Keep a check on weight: ______ [yes/no]

Details of Allergies:

Date:                 Allergic to?                 Symptoms and reactions

[Make a list of all the allergies and their symptoms and reactions date wise]

Health history

Condition:          [Yes/no]             Medication used          When were you diagnosed

Cancer, type





Chronic conditions

Heart disease


High /low blood pressure


Drug name         dosage              directions   Purpose     date started

[Make a list of all medications used and all the other details in the columns given]

List of surgeries/ailments:

Surgery name             Body part affected               when

[Make a list of all the surgeries you have undergone and how they affected you]