SF504

Medical Record - History - Part 1

Agency
GSA
Revision
Rev. 5/2025
Fillable fields
16
Pages
2
Official source
GSA form page
Checked
October 20, 2026
Fill SF504 online
Page 1 of form SF504

Standard Form 504 (SF 504): Medical Record - History - Part 1

Standard Form 504 (SF 504), Medical Record - History - Part 1, is a two-sided medical record form, Rev. 5/2025. Its footer says it is prescribed by GSA/ICMR under FMR (41 CFR) 102-194.25(i), and the form is marked Authorized for Local Reproduction. GSA hosts a copy in its forms library.

The front records the nature and duration of complaints, including the circumstance of admission, and the history of present illnesses, which continues on the reverse side. The bottom of the front identifies the patient, the sponsor, the department or service and the hospital or medical facility.

The PDF prints no instructions, signature line, privacy notice or filing address. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Standard Form 504 (SF 504): Medical Record - History - Part 1, as printed by GSA

What's on SF 504

Nature and duration of complaints

A free-text area for the nature and duration of complaints, including the circumstance of admission.

History of present illnesses

A free-text area for the history of present illnesses, marked Continue on reverse side.

Sponsor details

Relationship to sponsor, sponsor's name (last, first, middle initial) and sponsor's ID number (SSN or other).

Facility and patient identification

Department/service, hospital or medical facility, records maintained at, patient's identification, register number and ward number.

Back: history continued

The reverse side is headed History of Present Illnesses (Continued).

How to complete SF 504

  1. 1

    Describe the complaints

    Enter the nature and duration of complaints. The form says to include the circumstance of admission.

  2. 2

    Write the present illnesses

    Record the history of present illnesses in the area below.

  3. 3

    Continue on the back

    The front says Continue on reverse side, and the back carries on the history of present illnesses.

  4. 4

    Add the sponsor and facility details

    Fill in the relationship to sponsor, the sponsor's name and ID number, the department/service, the facility, where records are maintained, and the register and ward numbers.

  5. 5

    Identify the patient

    For typed or written entries, the form says to give the name (last, first, middle), ID number or SSN, sex (male or female), date of birth and rank/grade.

The form prints no step-by-step instructions. These steps follow its blocks.

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Records and what the form says

Where it goes

The PDF gives no filing address. A block on the form records where the records are maintained.

Prescribing rule

The footer reads Prescribed by GSA/ICMR FMR (41 CFR) 102-194.25(i).

Copies

The form is marked Authorized for Local Reproduction.

Related forms

Who fills out SF 504?

  • The hospital or medical facility

    Blocks record the department/service, the hospital or medical facility and where the records are maintained, with a register number and ward number.

  • The patient

    The patient's identification block asks for the name, ID number or SSN, sex, date of birth and rank/grade.

  • The sponsor

    A row records the relationship to sponsor and the sponsor's name and ID number (SSN or other).

  • Who writes the history

    Part 1 has no signature or date line, and the form does not say who writes the history.

The form prints no instructions on who completes it. Its blocks point to these roles and places.

Official sources and the blank

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Questions about Form SF504

Who prescribes SF 504?

The footer says the form is prescribed by GSA/ICMR under FMR (41 CFR) 102-194.25(i). GSA hosts a copy in its forms library.

What does Part 1 of the history cover?

The nature and duration of complaints, including the circumstance of admission, and the history of present illnesses.

What if the history needs more room?

The front says Continue on reverse side. The back is headed History of Present Illnesses (Continued).

Does SF 504 have a signature line?

No. The PDF prints no signature or date line on either side.

How is the patient identified on SF 504?

For typed or written entries, the form asks for the name (last, first, middle), ID number or SSN, sex (male or female), date of birth and rank/grade, with a register number and ward number.