Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Clinical Assessment Form Template

Streamline Patient Evaluations with Our Template

Collecting accurate patient information can be time-consuming and prone to errors. This Clinical Assessment Form Template helps healthcare providers gather comprehensive data efficiently to enhance patient care. Enjoy benefits like simplified data entry, reduced paperwork, improved patient compliance, and the ability to analyze trends over time, all while ensuring adherence to WCAG-aligned accessibility standards. Explore the live template to get started with ease.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Mobile phone number
Email address
Emergency contact full name
Emergency contact phone number
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Primary reason for assessment today
How long has this been a concern?
Less than 1 week
1-4 weeks
1-3 months
3-12 months
More than 12 months
Not sure
Is it okay to leave voicemail or text messages with appointment or care information?
Yes
No
Which symptoms or areas are you experiencing now?
Please Specify:
Do you have any ongoing or past medical conditions?
Please Specify:
Have you had any surgeries?
Yes
No
Do you have any allergies?
No known allergies
Medication allergies
Food allergies
Environmental (e.g., pollen, dust)
Latex
Other
Please Specify:
Please list allergens and reactions (if any).
Please list current medications with dose and frequency.
Are you currently taking any medications?
Yes
No
In the past 2 weeks, how often have you had little interest or pleasure in doing things?
Very rarely
Rarely
Sometimes
Often
Very often
In the past 2 weeks, how often have you felt down, depressed, or hopeless?
Very rarely
Rarely
Sometimes
Often
Very often
Do you currently use any of the following?
Do you feel safe at home?
Yes
No
Prefer not to say
In the past month, have you had thoughts of harming yourself?
No
Yes - passive thoughts (no plan)
Yes - active thoughts (no plan)
Yes - active thoughts with plan
Prefer not to say
Insurance provider
Policy or member ID number
Type your full legal name to sign
Date of consent
I consent to participate in a clinical assessment and share relevant information with my care team.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth, Mobile phone number","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a clinical assessment form template for FormCreatorAI article

When to use this form

Use this form before a first visit, at annual reviews, after hospital discharge, or when symptoms change. It helps you capture history, current complaints, risks, and function so you can set priorities and plan care. Clinicians, care coordinators, and students benefit; patients avoid repeating the same story. Pair it with a Head to toe assessment form for a full physical check, and add the Blood pressure monitoring form if someone tracks home readings. For pre-employment or insurance reviews, include a Statement of health form to document baseline status. The result is a clear snapshot that supports triage, safe prescribing, and referrals.

Must Ask Clinical Assessment Questions

  1. What brings you in today, and what are your top concerns?

    This open question surfaces the chief complaint in your words, so the care team can focus on what matters. It also sets expectations and helps prioritize urgent issues first.

  2. When did your symptoms start, and how have they changed over time?

    Onset, duration, and pattern point to likely causes and severity. This timeline guides testing and whether you need same-day care.

  3. Do you have any chronic conditions, past surgeries, or hospitalizations?

    Past conditions and procedures reveal risks, contraindications, and context for current symptoms. This background prevents missed diagnoses and unsafe orders.

  4. What medications and supplements do you take, including dose and frequency?

    A complete medication list prevents interactions and duplicate therapy. Doses and schedules also flag adherence issues that may drive symptoms.

  5. Do you have any allergies or adverse reactions, and what happens during an exposure?

    Specific reactions and triggers shape safety plans and avoid cross-reactive drugs. If needed, you can prepare an Allergy action plan form for prevention and emergencies.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel