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General Health Appraisal Form Template

Streamline Health Assessments with Our Template

Are you struggling to gather crucial health information from clients or employees? This General Health Appraisal Form Template helps you efficiently collect valuable data about an individual's health status, lifestyle, and medical history. By using this template, you can simplify health screenings, enhance patient care, and ensure compliance with health regulations-all while streamlining your data collection process. Start creating effective health assessments today with our easy-to-use template that features WCAG-aligned labels for accessibility.

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Full name
Date of birth
Age range
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Email address
Phone number
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Type your name as signature
Signature date
Do you consent to the collection and use of your health information for this appraisal?
Yes
No
Have you ever been diagnosed with any of the following conditions?
Please Specify:
If other conditions, please specify
Please provide details and approximate dates for surgeries or hospitalizations
Have you had any surgeries or hospitalizations?
Yes
No
List your current medications and supplements with doses, or type None
List specific allergens and reactions, or type None
Do you have any allergies?
No known allergies
Medications
Foods
Environmental (e.g., pollen, animals)
Latex
Insect stings
Unsure
Other
Please Specify:
If cancer or other conditions, please specify and relation
Do any close blood relatives have the following?
Height (please include units)
Weight (please include units)
Tobacco use
Never
Former
Currently - cigarettes
Currently - vaping
Currently - smokeless tobacco
Prefer not to say
Alcohol use frequency
Never
Rarely
Sometimes
Often
Always
Exercise frequency (moderate to vigorous)
Never
Rarely
Sometimes
Often
Always
Typical sleep per night
Less than 5 hours
5-6 hours
7-8 hours
9 or more hours
Varies a lot
Not sure
Please describe any current symptoms or concerns
Are you currently experiencing any of the following symptoms?
Do you have a primary care clinician?
Yes
No
When was your last general checkup?
Within the past year
1-2 years ago
Over 2 years ago
Never
Not sure
Are your vaccinations up to date?
Yes
Some
No
Not sure
Over the past 2 weeks, how often have you felt down, depressed, or hopeless?
Very rarely
Rarely
Sometimes
Often
Very often
Over the past 2 weeks, how often have you felt nervous, anxious, or on edge?
Very rarely
Rarely
Sometimes
Often
Very often
Do you currently have thoughts of harming yourself or others?
No
Yes
Prefer not to say
Do you need help with daily activities (e.g., bathing, dressing, shopping, managing medications)?
No, I am independent
Yes, some help
Yes, a lot of help
Unable to perform without help
Prefer not to say
Have you fallen in the past 12 months?
Yes
No
Do you feel safe at home?
Yes
No
Sometimes
Prefer not to say
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Paper art illustration depicting health appraisal form elements for article on General Health Appraisal Form Template FormCreatorAI

When to use this form

Use this form during new patient intake, annual checkups, workplace wellness enrollments, or telehealth triage. It gives you a quick, structured view of medical history, lifestyle risks, and current symptoms, so you can prioritize care and set baselines. Clinics can pair it with the Nursing assessment form to build care plans. If answers suggest complex issues, hand off to the Medical assessment form for a deeper review. When you need documentation for employers or insurers, export responses alongside a Statement of health form. For community health drives or school screenings, it helps you flag people who need follow-up and track progress over time.

Must Ask General Health Appraisal Questions

  1. What are your main health concerns today?

    This focuses the visit on what matters most to you and sets clear goals. It also helps triage urgency, so urgent issues get priority.

  2. Do you have any diagnosed conditions, past surgeries, or hospitalizations?

    History reveals risks and contraindications that can change screening or treatment choices. Knowing timelines and diagnoses keeps records consistent and reduces follow-up calls.

  3. List all medications, supplements, and allergies.

    This prevents harmful interactions and guides safe prescribing. It also explains side effects that may mimic new symptoms.

  4. Describe your typical weekly activity, sleep, and diet.

    Lifestyle patterns influence blood pressure, weight, mood, and recovery. If you need more detail, attach a Food diary form to track meals over several days.

  5. Have you noticed any new pain, numbness, weakness, headaches, or balance changes?

    These red flags point to possible nerve or brain issues that require faster evaluation. If present, follow up with a Neurological exam form.

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