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Health Examination Form Template

Streamline Patient Assessments with Our Health Examination Form

If gathering patient health information feels overwhelming, this health examination form template is here to help you. Designed for healthcare providers, it simplifies the process of collecting vital health details to enhance patient care. With this template, you can efficiently track medical history, note symptoms, and assess overall wellness, all while ensuring compliance with privacy standards. Plus, it's user-friendly and can be customized for various medical practices. Start streamlining your patient assessments now by exploring the live template!

Use this Template (FREE) Live Preview
Full name
Date of birth
Email address
Phone number
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Emergency contact full name
Emergency contact phone number
Which of the following conditions have you been diagnosed with? (Select all that apply)
Have you had any surgeries or hospitalizations in the past 5 years?
Yes
No
Any family history of the following? (Select all that apply)
Please list any current medications or supplements (or write 'None')
Please list allergy details and reactions (if any)
Do you have any allergies?
No known allergies
Medication allergies
Food allergies
Environmental allergies
Prefer not to say
Other
Please Specify:
Tobacco use
Never
Former
Current daily
Current occasional
Prefer not to say
Alcohol use frequency
Never
Rarely
Sometimes
Often
Always
Prefer not to say
Physical activity frequency
Never
Rarely
Sometimes
Often
Always
Height (please include units, e.g., cm or in)
Weight (please include units, e.g., kg or lb)
Are you experiencing any of the following today? (Select all that apply)
Preferred appointment date
Type your full name to provide consent
Date of consent
I consent to undergo this health examination and for my information to be securely processed for care
Yes
No
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Paper art illustration depicting a health examination form layout and design elements for FormCreatorAI article

When to use this form

Use this form for routine checkups, pre-employment exams, sports clearances, and pre-op assessments. It helps you gather history, symptoms, vitals, and risks in one place so your team can act fast. Front-desk staff can start intake online, nurses can complete measurements, and clinicians can review and sign. Pair it with the Patient demographic information form to prefill contact and insurance details, and add the Doctor information form to capture credentials and signatures. You will reduce back-and-forth, avoid missed questions, and produce a clear record for referrals, school or workplace requirements, and billing.

Must Ask Health Examination Questions

  1. What brings you in today, and when did your symptoms start?

    This captures the chief complaint and timeline so you can prioritize care and choose the right exam scope. For a structured narrative, pair brief notes here with the HPI Form.

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

    Knowing baseline health and major events reveals risks and contraindications. It also guides screening and coding; you can summarize these in the Medical summary form.

  3. Which medications and supplements do you take, and do you have any drug or food allergies?

    Medication lists and allergies prevent dangerous interactions and reactions. They guide safe prescribing and help you decide what to stop before tests or procedures.

  4. What is your typical activity level, job duties, and any recent exposures or travel?

    Lifestyle and occupational context surface overuse injuries, environmental hazards, and infectious risks. This shapes advice, work notes, and return-to-activity plans.

  5. Are you having any red-flag symptoms such as chest pain, severe shortness of breath, fainting, or neurological deficits?

    Screening for urgent warning signs triggers immediate testing or referral and improves safety. You can document vitals and objective findings alongside this screening in the Patient encounter form.

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