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Health Screening Form Template

Streamline Your Health Assessments with Ease

Struggling to keep track of your health assessments? This health screening form template is designed specifically for healthcare professionals and organizations like yours to efficiently evaluate individual health statuses and identify symptoms. By using this template, you can enhance patient engagement, streamline information collection, and help implement effective preventive measures against contagious diseases. Plus, it's designed with WCAG-aligned labels for accessibility. Start using the live template to simplify your health screenings today!

Use this Template (FREE) Live Preview
Full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email address
Phone number
Preferred screening date
Preferred contact method
Email
Phone
Either
Have you been diagnosed by a healthcare professional with any of the following?
Family history (parents, siblings, grandparents) of the following
Heart disease
Stroke
Diabetes
High blood pressure
High cholesterol
None of the above
Not sure
Are you experiencing any of the following today?
Are you currently pregnant?
Yes
No
Not applicable
Prefer not to say
Current medications and supplements (include doses if known)
Allergies (medications, foods, or other)
Tobacco or nicotine use
Never
Former
Occasionally
Daily
Prefer not to say
How often do you drink alcoholic beverages?
Never
Rarely
Sometimes
Often
Always
On a typical week, how many days do you get 30+ minutes of physical activity?
0 days
1-2 days
3-4 days
5-7 days
Prefer not to say
Height (please include units, e.g., cm or ft/in)
Weight (please include units, e.g., kg or lb)
Most recent blood pressure reading (if known)
Emergency contact full name
Emergency contact phone number
Type your full name to sign
Date of signature
I consent to participate in this free health screening and to be contacted about my results.
Yes
No
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paper art illustration showcasing a health screening form template with various sections and checkboxes for data entry

When to use this form

Use this health screening form before appointments, on first visits, or to check readiness for work, school, or events. Clinics and occupational health teams can triage symptoms, flag risks, and document next steps in a shareable health screening report. For surgical candidates, pair it with the Pre-op clearance form to streamline preoperative checks. HR can assess fitness to resume duties and note restrictions alongside a Return to work form. Community programs can capture exposure history, travel, and vaccination details to guide testing or isolation. You get consistent data, faster intake, and fewer follow-up calls.

Must Ask Health Screening Questions

  1. What symptoms do you have right now, and when did they start?

    This pinpoints urgency and helps you triage who needs immediate care versus routine follow-up. Onset timing also informs contagion windows and testing choices.

  2. Have you had close contact with someone ill or been exposed to a known infectious disease in the past 14 days?

    Exposure risk guides isolation, masking, and testing recommendations. For TB-specific programs, direct high-risk cases to the TB Screening form.

  3. Do you have any chronic conditions, allergies, or medications we should know about?

    These details change risk assessment and which treatments or vaccines are safe. Clinicians can verify history with a Medical chart review form before making decisions.

  4. Have you had any recent procedures, hospital visits, or do you have a planned surgery?

    Recent care can explain symptoms, affect lab results, and signal post-op complications. It also helps you coordinate follow-up with the surgical team.

  5. What work, school, or activity are you seeking clearance for, and what are the physical demands?

    Context ties recommendations to the role, such as lifting limits or mask requirements. It prevents vague notes and supports safer, faster clearances.

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