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Medical Assessment Form Template

Efficiently Gather Patient Information with This Template

Struggling to collect vital patient information efficiently? Our Medical Assessment Form Template streamlines the process of gathering crucial medical history from potential patients, ensuring you get the insights you need for quality care. This easy-to-use template helps healthcare providers capture comprehensive data, assess health risks, and enhance patient engagement, all while complying with HIPAA standards for data privacy. You can now simplify your workflow and focus more on patient care-try out the live template today.

Use this Template (FREE) Live Preview
Full name
Date of birth
Email
Phone number
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Please describe your main health concern or reason for this assessment
When did this concern begin?
How would you rate the severity of your main concern?
Mild
Moderate
Severe
Not sure
Are you experiencing any of the following symptoms?
Which of the following conditions have you been diagnosed with? (Select all that apply)
Current medications and supplements (include doses if known)
List any allergies and reactions
Do you have any allergies?
Yes
No
Tobacco use
Never
Former
Current some days
Current every day
Prefer not to say
Height (please include units, e.g., cm or ft/in)
Weight (please include units, e.g., kg or lb)
Alcohol use frequency
Never
Rarely
Sometimes
Often
Always
Insurance provider (if applicable)
Emergency contact full name
Emergency contact phone
Do you have health insurance?
Yes
No
I authorize the provider to collect and review this information for a medical assessment.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I consent to be contacted by phone or email about this assessment.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Signature (type your full name)
Signature date
I confirm the information I provided is accurate to the best of my knowledge.
True
False
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Paper art illustration depicting a medical assessment form and tools for an article on FormCreatorAI

When to use this form

Use this template when you need a complete health intake for new patients, urgent visits, or pre-op checks. It suits clinics, telehealth teams, school health programs, and workplace screenings. Capture symptoms, history, medications, vitals, and risks in one place so you can triage faster and set a safe plan. For a detailed exam, pair it with the Head to toe assessment form. When you need a diagnostic summary for referrals, your Clinical assessment form complements it well. If a patient monitors at home, ask them to attach the Home blood pressure report form. The result is clear, structured data that reduces back-and-forth and supports better decisions.

Must Ask Medical Assessment Questions

  1. What is your main concern today, and when did it start?

    Onset and timeline help you judge urgency and choose the right tests. Clear symptoms and duration also guide the next best step in care.

  2. Do you have any chronic conditions or significant past surgeries or hospitalizations?

    History shapes risk, treatment options, and follow-up needs. It also flags complications that might change todays plan.

  3. Which medications, supplements, or herbal products do you take, and do you have any allergies?

    A complete list prevents dangerous interactions and adverse reactions. It supports safe prescribing and correct dosing.

  4. Have you recorded recent vitals (blood pressure, pulse, temperature, weight) or home readings such as glucose?

    Objective data shows baseline versus today and helps confirm or rule out instability. Trends can validate improvement or signal deterioration.

  5. What does a typical day of eating and drinking look like for you?

    Diet can drive weight, blood pressure, glucose control, and GI symptoms. If nutrition is a factor, you can request a Food diary form to capture details over a week.

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