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Health Risk Assessment Questionnaire Form Template

Elevate Your Patient Care with This Comprehensive Assessment Template

Managing health risks can feel overwhelming, especially when trying to identify factors that may affect patient well-being. This health risk assessment questionnaire form template is designed for healthcare providers seeking to efficiently assess and track their patients' risk factors. With this template, you can streamline patient data collection, enhance health monitoring, and provide personalized care plans, ultimately fostering better patient outcomes. Experience how easy it is to gather essential health information by trying out the live template today.

Use this Template (FREE) Live Preview
I understand this assessment is informational and not a medical diagnosis.
Yes
No
Type your full name as your signature
Date
I consent to the processing of my information for this assessment.
Yes
No
Date of birth
Height (please include unit, e.g., cm or ft/in)
Weight (please include unit, e.g., kg or lb)
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Smoking or vaping status
Never
Former
Current some days
Current every day
Prefer not to say
Alcohol consumption frequency
Never
Rarely
Sometimes
Often
Always
How often do you do at least 30 minutes of moderate physical activity?
Very rarely
Rarely
Sometimes
Often
Very often
How often do you feel stressed or anxious?
Very rarely
Rarely
Sometimes
Often
Very often
Do you have any of the following conditions? (Select all that apply)
Current prescription medications or supplements
Allergies (medications, foods, environmental)
Have you had a cholesterol test in the past 2 years?
Yes
No
Not sure
Family history in first-degree relatives (Select all that apply)
When was your last general health check-up?
Within the past 12 months
1-2 years ago
More than 2 years ago
Never/Not sure
Which of the following have you completed in the past 2 years? (Select all that apply)
Do you currently have any symptoms or concerns?
Yes
No
Please describe any current symptoms or concerns
Overall, how would you rate your health?
Poor
Fair
Good
Very good
Excellent
Email
May we contact you with your assessment summary?
Yes
No
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Paper art illustration depicting a health risk assessment questionnaire form for a digital template.

When to use this form

Use this assessment when you onboard new patients, run an employee wellness program, or prepare for an annual checkup. It helps you gather medical history, lifestyle habits, family risks, and preventive care in one pass, so you spot red flags early and prioritize follow-up. Clinics and occupational health teams can set a baseline and track changes; insurers and wellness coaches can tailor outreach and education. For a complete picture, pair it with a Medical assessment form for vitals and exam findings, and add a Nutritional assessment questionnaire form to explore diet-related risks. If return-to-work or disability is in scope, include a Functional capacity evaluation form to assess activity limits.

Must Ask Health Risk Assessment Questionnaire Questions

  1. What current medical conditions do you have, and have you had any surgeries or hospitalizations?

    This gives a clear snapshot and flags issues that change screening and counseling. Surgical and hospital history also reveals complications or risks that affect care plans.

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

    A complete list helps you avoid harmful interactions and make safe, effective recommendations. Allergy details protect against adverse events and guide referrals if specialized care is needed.

  3. Do you smoke, vape, drink alcohol, or use recreational drugs, and how active are you each week?

    Substance use and activity level drive heart, cancer, and injury risk. With concrete data, you can set realistic goals and targeted supports.

  4. Do any close relatives have heart disease, diabetes, stroke, or cancer, and at what age were they diagnosed?

    Family history helps you gauge inherited risk and adjust screening intervals sooner if needed. Age of onset sharpens risk estimates and counseling.

  5. When was your last blood pressure check, cholesterol test, cancer screening, and routine vaccination?

    Preventive care status shows gaps you can close quickly. Document next steps in a Treatment plan development form to turn gaps into actionable orders or referrals.

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