Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Patient Assessment Form Template

Streamline your patient evaluations effortlessly

Accurate patient evaluations can feel overwhelming, but they're essential for effective healthcare. This Patient Assessment Form template is designed for healthcare providers who need a clear, structured method to evaluate patient health status comprehensively. With features like easy navigation, customizable fields, and compliance with WCAG-aligned standards, you can collect vital information seamlessly, improve patient communication, facilitate follow-ups, and enhance treatment planning. Start optimizing your assessments with this practical template now.

Use this Template (FREE) Live Preview
Full legal name
Date of birth (MM/DD/YYYY)
Primary phone number
Email address
Home address
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Emergency contact full name
Emergency contact phone number
Primary reason for your visit today
Which symptoms are you experiencing?
Current pain level
Have you been diagnosed with any of the following conditions?
Other diagnosed conditions (optional)
Past surgeries or hospitalizations (include year, if known)
Allergies (list allergens and reactions, or type NKA if none)
Are you currently pregnant?
Yes
No
Not applicable
Prefer not to say
Current medications and supplements (name, dose, frequency)
Tobacco use
Never
Former
Current daily
Current occasional
Prefer not to say
Alcohol use frequency
Never
Rarely
Sometimes
Often
Always
Height and weight (include units)
Do you have any regular physical activity or exercise routine?
Never
Rarely
Sometimes
Often
Always
Insurance provider
Member ID
Policy holder name
Preferred contact method
Phone call
Text message
Email
No preference
Do you have any language or accessibility needs?
Language interpreter
Sign language interpreter
Wheelchair access
Large print materials
Visual assistance
Hearing assistance
None
Other
Please Specify:
I confirm the information I have provided is accurate to the best of my knowledge
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I consent to evaluation and treatment by this provider
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Electronic signature (type full name)
Signature date
I consent to be contacted about appointments and care via phone, text, or email
Yes
No
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth (MM\/DD\/YYYY), Primary phone number","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration featuring a patient assessment form with medical graphics and notes for FormCreatorAI article

When to use this form

Use this assessment form at intake, during annual checkups, or before a procedure to capture history, symptoms, medications, and risks. It helps front-desk staff, nurses, and clinicians build a complete picture fast, so you avoid missed details and repeat questions. In urgent care, it flags red flag symptoms for triage. In primary care or telehealth, it standardizes updates between visits and pairs well with the Symptom screening form for quick pre-visit reviews. For chronic conditions, connect responses to a Blood pressure monitoring form and a Medical report form to track trends and document care. Dietitians can also pair it with a Food diary form to assess nutrition and fatigue triggers.

Must Ask Patient Assessment Questions

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

    This establishes the chief concern and timeline, which guides triage and testing. Clear onset details help you spot patterns and rule out urgent causes.

  2. Do you have any chronic conditions or previous surgeries?

    History shapes risk, medication choices, and follow-up needs. Knowing prior procedures prevents repeat imaging and alerts you to complications.

  3. Which medications, supplements, or allergies should we know about?

    This prevents dangerous interactions and allergic reactions. It also helps you reconcile dosages and avoid duplicate therapies.

  4. What is your recent blood pressure, heart rate, and temperature?

    Baseline vitals confirm stability and reveal trends. Abnormal values guide immediate care and indicate if closer monitoring is needed.

  5. Has anything changed in your diet, sleep, or stress levels recently?

    Lifestyle shifts can drive symptoms like headaches, GI issues, and fatigue. Capturing recent changes points you to root causes and realistic self-care steps.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel