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Health Profile Form Template

Create comprehensive health profiles for better patient care

Gathering your patients' health information shouldn't be complicated. This health profile form template helps healthcare providers like you collect essential data, leading to personalized care and better treatment outcomes. Benefit from streamlined data collection, improved patient communication, and a clear overview of medical histories, enabling you to focus more on patient relationships and less on paperwork. Start using the live template to enhance your practice's efficiency.

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Full name
Date of birth
Email address
Mobile phone
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Emergency contact full name
Emergency contact phone
Please list any ongoing medical conditions or diagnoses (if any)
Please list any past surgeries or hospitalizations (include dates if known)
Please list any allergies and reactions (medications, foods, environmental) if any
Please list any current medications and supplements with doses (if any)
Are your immunizations up to date?
Yes
No
Not sure
Do you currently use any tobacco or nicotine products?
Never
Former user
Some days
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 exercise for at least 30 minutes?
Never
Rarely
Sometimes
Often
Always
What is the main reason for completing this health profile?
Please describe any current symptoms or concerns (if any)
Please list any significant family health conditions (include relation and condition) if any
Name (type your full name as signature)
Date
I confirm the information provided is accurate to the best of my knowledge
Yes
No
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Paper art illustration showing a health profile form for a FormCreatorAI article on form templates

When to use this form

For new patient onboarding, annual updates, or pre-visit screening, use this form to gather the facts you need in one pass. It helps primary care teams, specialists, and telehealth staff spot risks, tailor care, and speed check-in. Send it before an appointment so nurses can flag red flags and doctors can prepare a plan. In community clinics, it supports quick triage during walk-ins. You can also pair it with the Medical intake form to capture demographics and insurance, and reference the Medical history form to import past conditions and surgeries. The result: fewer follow-up calls, safer decisions, and a clearer picture of each person's health.

Must Ask Health Profile Form Questions

  1. What are your primary health concerns or goals?

    This focuses your visit and helps the team prioritize what matters most to you. It also gives context for symptoms and aligns with the Patient encounter form for clear follow-up notes.

  2. Which medications, supplements, and dosages are you currently taking?

    Accurate lists prevent drug interactions and duplicate therapies. Knowing dosages speeds safe prescribing and reduces back-and-forth calls.

  3. Do you have any allergies or past adverse reactions?

    This protects you during exams, imaging, and procedures. It also guides medication choices and preps the care team to avoid triggers.

  4. What past diagnoses, surgeries, or hospitalizations should we know about?

    History reveals risk factors and patterns that shape today's decisions. It helps choose appropriate screenings, labs, and referrals.

  5. Do you have pain or mobility issues that affect daily activities?

    Detailing location, severity, and triggers helps tailor treatment and accommodations. For musculoskeletal cases, the Chiropractic intake form provides added context the team can use.

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