Comment by wrs

Because you filled it out in the context of interacting with a medical provider, then gave it to them for their records, that is a medical record. (Just like a conversation with your doctor about your history would be.)

If you filled out the same form just to keep in your desk drawer for your family’s reference, it would not be. Also, if you ask for a copy of your record, as soon as you take personal possession of it, HIPAA no longer cares about it, because you aren’t a covered entity.

(Source: I founded a startup that spent a lot of money on attorneys to confirm this.)