Home health nurse template for patient history and visit notes
This nurse template gives you one printed page for the history you take at a home visit, starting with patient name, date of birth, presenting complaint and the date.
Medication, allergies & family history sit together on the same sheet. You can hand it to another provider without copying anything out. Examination/notes closes the page.
Fields on the home health nurse template
- Patient name
- Date of birth
- Presenting complaint
- Date
- History of presenting complaint
- Medical & surgical history
- Medication
- Family history
- Allergies
- Examination/notes
Using it at a first visit
Fill it in when you open a chart for a new patient at home, working down the page from complaint to allergies. The examination/notes section works as a nurse notes template for your findings on the day, and the sheet is one of our home health documentation templates for nurses who work outside a hospital.
Sizes & colors
You'll get a zipped folder of PDF files in A4 and US Letter sizes, with 7 color schemes to choose from or mix:
- Rainbow (red, orange, yellow, green, blue, pink, purple)
- Ocean (blues & greens)
- Fruity (pinks & purples)
- Bubblegum (pinks, purples, blues & greens)
- Flame (reds, oranges & yellows)
- Forrest (greens)
- Bohemian (browns & tans)
Questions about this nurse template
Can I type into it on my computer? No, it's a print-only PDF, so you'll write each field in by hand after printing.
Related nursing printables
See all nurse & nursing student printables and printables for caregivers.
This is a record-keeping sheet, not medical advice. Follow your healthcare provider's guidance.
Instant digital download; nothing is shipped. PDF files aren't editable. For personal use only; please don't redistribute or resell. © Plan Print Land
