SF505
Medical Record - History - Parts 2 and 3
Standard Form 505 (SF 505), Medical Record - History - Parts 2 and 3, is a two-sided medical record form, Rev. 5/2025. Its footer says it is prescribed by GSA/ICMR under FMR (41 CFR) 102-194.30(i). The form is marked Authorized for Local Reproduction and says the previous edition is not usable. GSA hosts a copy in its forms library.
Part 2, Past History, on the front lists nine topics to include, from occupation and military history to drug sensitivities and allergic reactions. Part 3, System Review, on the back lists 16 numbered items to include, from general and head through the body systems, and ends with the physician's signature and date. The front also identifies the patient, the sponsor and the hospital or medical facility.
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Instructions to include occupation (civilian and military), military history with geographic locations and dates, habits (alcohol, tobacco, and drugs), family history, childhood illnesses, adult illnesses, operations, injuries, and drug sensitivities and allergic reactions.
Relationship to sponsor, sponsor's name and ID number, department/service, hospital or medical facility, records maintained at, patient's identification, register number and ward number.
The back starts with last name, first name, middle initial and ID number.
Instructions to include general, head (with eye, ear, nose and throat), neck, respiratory, cardiovascular, gastrointestinal, genitourinary, gynecological, hemopoietic, lymphatic, musculoskeletal and neuropsychiatric systems, 16 numbered items in all.
Signature of physician and date at the bottom of the back.
Part 2 says to include the nine numbered topics, from occupation and military history through habits, family history, illnesses, operations, injuries and allergic reactions.
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, plus the sponsor details.
Fill in the department/service, the hospital or medical facility, where records are maintained, and the register and ward numbers.
Enter the last name, first name, middle initial and ID number at the top of the back.
Part 3 says to include the 16 numbered items of the system review.
The back ends with the signature of physician and the date.
The form prints instructions for each part. These steps follow its blocks.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The PDF gives no filing address. A block on the form records where the records are maintained.
The footer reads Standard Form 505 (Rev. 5/2025), and the top of the form says the previous edition is not usable.
The footer reads Prescribed by GSA/ICMR FMR (41 CFR) 102-194.30(i). The form is marked Authorized for Local Reproduction.
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The form does not say who writes the history. Its blocks name these roles and places.
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The footer says the form is prescribed by GSA/ICMR under FMR (41 CFR) 102-194.30(i). GSA hosts a copy in its forms library.
Past history. The form says to include occupation (civilian and military), military history, habits (alcohol, tobacco, and drugs), family history, childhood illnesses, adult illnesses, operations, injuries, and drug sensitivities and allergic reactions.
System review. The form lists 16 numbered items, including general, head, eye, ear, nose, throat, neck, respiratory, cardiovascular, gastrointestinal and musculoskeletal.
The back has a Signature of Physician line with a date. The front has no signature line.
The Rev. 5/2025 edition says at the top that the previous edition is not usable.