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Health Assessment Form Template

Streamline patient data collection with our Health Assessment Form

You need an efficient way to gather comprehensive health information from patients, and this Health Assessment Form template is designed to help you do just that. Perfect for healthcare practitioners and wellness coordinators, this template ensures you collect essential data for accurate assessments and improved patient care. Benefit from easy customization, quick data input, and streamlined reporting, along with compliance-friendly features like WCAG-aligned labels. Explore the live template to see how it can simplify your process and enhance patient interactions.

Use this Template (FREE) Live Preview
Full name
Date of birth
Email
Phone number
Emergency contact full name
Emergency contact phone number
What is your gender?
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Do you have a primary care clinician?
Yes
No
Please indicate any current or past conditions (select all that apply).
Please list any surgeries or hospital stays (include dates if known).
Any family history of the following? (select all that apply)
Tobacco use status
Never
Former
Occasional
Daily
Prefer not to say
Alcohol intake frequency
Never
Monthly or less
2-4 times per month
2-3 times per week
4 or more times per week
Prefer not to say
Physical activity frequency
Very rarely
Rarely
Sometimes
Often
Very often
Average sleep per night
<5 hours
5-6 hours
7-8 hours
9+ hours
Varies
Height (include units, e.g., cm or ft/in)
Weight (include units, e.g., kg or lb)
What symptoms are you experiencing? (select all that apply)
Please Specify:
How are your symptoms changing over time?
Getting worse
No change
Improving
Not applicable
Please list all current medications and supplements (names and doses).
Please list allergy details and reactions.
Do you have any allergies? Select all that apply.
Medication
Food
Environmental (e.g., pollen, dust)
Latex
Insect stings
No known allergies
Unsure
Other
Please Specify:
In the past 2 weeks, how often have you felt nervous, anxious, or on edge?
Very rarely
Rarely
Sometimes
Often
Very often
Are you currently pregnant or planning a pregnancy in the next year?
Yes
No
Not applicable
Prefer not to say
Are your vaccinations up to date?
Yes
No
Unsure
I confirm the information provided is accurate to the best of my knowledge.
True
False
Signature
Date
I consent to be contacted regarding this assessment.
Yes
No
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Paper art illustration depicting a health assessment form template for FormCreatorAI article

When to use this form

This form fits intake at clinics and telehealth, wellness visits, and employee screenings. Use it to collect history, symptoms, medications, and risks in one place. It helps you triage, document, and plan care or workplace accommodations. For preventive programs, pair it with the Health risk assessment questionnaire form to map long-term risks. During outbreaks or urgent visits, add the Symptom screening form to quickly identify red flags. If a clinician must complete part of the record, route the results to the Medical assessment form. Typical uses include new patient onboarding, annual checkups, school or sports clearance, and chronic condition check-ins. The outcome: faster decisions, fewer follow-up emails, and a clear, auditable record.

Must Ask Health Assessment Form Questions

  1. What is your main health concern today, and when did it start?

    Stating your top concern and onset frames the visit and shows how the issue is changing. It helps triage urgency and supports the Doctor diagnosis form if a provider needs to document findings.

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

    History of conditions and surgeries changes risk, screening needs, and medication choices. It prevents repeat testing and points to complications to watch.

  3. What medications and supplements do you take, including doses and frequency?

    Current medicines and supplements reveal interactions, side effects, and adherence issues. Doses and timing help your provider adjust treatment safely.

  4. Do you have any allergies or prior adverse reactions to medications, foods, or materials?

    Documenting allergies and prior reactions prevents harmful exposures. It guides safe alternatives for drugs, vaccines, and materials used during care.

  5. What lifestyle factors affect your health (tobacco, alcohol, activity, diet, sleep, stress)?

    Lifestyle inputs drive many conditions and affect recovery. If you need deeper diet insight, pair this with the Nutritional assessment questionnaire form.

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