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

Health Checklist Form Template

Monitor Your Health with This Comprehensive Checklist

Keeping track of your health can be overwhelming, but our Health Checklist Form Template makes it simple. This template is designed for anyone looking to assess and manage their health effectively, leading to better overall wellness. With this tool, you can easily identify risk factors, enhance your medical referrals, track health behaviors, and maintain personal health records, all while ensuring your data is organized and accessible. Start using the live template to take charge of your health today.

Use this Template (FREE) Live Preview
Full name
Date of birth
Email address
Phone number
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Do you have any of the following current conditions?
Do you have any allergies?
No known allergies
Medication allergies
Food allergies
Latex allergy
Environmental (pollen, dust, mold)
Insect stings
Prefer not to say
Other
Please Specify:
List your current medications and supplements (name and dose if known)
Have you had any surgeries or hospital stays in the past 5 years?
Yes
No
Does your immediate family have a history of any of the following?
Heart disease
Stroke
Cancer
Diabetes
High blood pressure
Mental health conditions
None of the above
Prefer not to say
Are your routine vaccinations up to date?
Yes
No
Not sure
Do you currently smoke or vape?
Never
Former
Current some days
Current every day
Prefer not to say
How often do you drink alcohol?
Never
Monthly or less
2-4 times a month
2-3 times a week
4+ times a week
Prefer not to say
How often do you get 30 minutes or more of physical activity?
Very rarely
Rarely
Sometimes
Often
Very often
Height (please include unit, e.g., cm or ft/in)
Weight (please include unit, e.g., kg or lb)
On a typical night, how many hours of sleep do you get?
Less than 5
5-6
7-8
9 or more
Prefer not to say
Are you currently experiencing any of the following?
Do you have pain today?
Yes
No
Over the past 2 weeks, how often have you felt stressed?
Very rarely
Rarely
Sometimes
Often
Very often
What are your top health goals for the next 3 months?
Over the past 2 weeks, how would you rate your overall mood?
Very unhappy
Unhappy
Neutral
Happy
Very happy
I understand this form is for general information and not for emergencies.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Type your full name as your signature
Date
I confirm the information provided is accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
{"name":"Full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name, Date of birth, Email address","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a health checklist form for a Health Checklist Form Template article.

When to use this form

Use this form before intake visits, pre-op screenings, school sports clearances, home care check-ins, and workplace wellness checks. It helps you capture symptoms, history, medications, allergies, and risks in minutes, so you can triage and plan care fast. Front-desk staff can send it ahead; patients complete it on any device. For deeper diagnostics, pair it with a Clinical assessment form. For nurse-led intake or home visits, add a Nursing assessment form to structure observations. The result: fewer gaps, safer decisions, and a clear next step for each person, including timely referrals when needed.

Must Ask Health Checklist Questions

  1. What are your current symptoms and when did they start?

    This captures severity, onset, and patterns. It lets you prioritize urgent cases and match patients to the right pathway.

  2. Do you have any diagnosed conditions or recent test results?

    Knowing confirmed conditions and recent labs or imaging prevents duplicate work and errors. If deeper history is required, route to a Medical assessment form.

  3. Which medications, supplements, or therapies are you currently using?

    Medication and therapy details help you prevent interactions and contraindications. They also support accurate medication reconciliation and safer orders.

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

    Documenting allergies and adverse reactions protects patients during prescribing, procedures, and vaccinations. It also triggers clear alerts and alternative options.

  5. Have you had any recent hospitalizations, surgeries, or injuries?

    Recent hospital stays, surgeries, or injuries explain new symptoms and recovery needs. They can also signal when to initiate a Rehab application form for therapy or support services.

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