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Self-Health Assessment Form Template

Streamline your personal health evaluation with our easy-to-use form

Feeling unsure about your health status can be stressful, especially when looking to make informed decisions. This Self-Health Assessment Form Template helps you evaluate your physical and mental well-being, empowering you to take charge of your health journey. With simplified questions to uncover symptoms, track habits, and reflect on your lifestyle choices, you can easily identify areas for improvement and engage in proactive health management. Start assessing your wellness effectively and confidentially with our user-friendly template.

Use this Template (FREE) Live Preview
Full name
Email address
What is your age?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
If you prefer to self-describe your gender, please write it here (optional)
What is your gender?
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Do you have any diagnosed medical conditions?
Yes
No
Please list any diagnosed conditions (optional)
Are you currently taking any prescribed medications or supplements?
Yes
No
Please list current medications or supplements, including dose if known (optional)
Please list allergies and typical reactions (optional)
Do you have any allergies to medicines, foods, or environmental factors?
Yes
No
On most days, how often do you engage in moderate physical activity (at least 30 minutes)?
Very rarely
Rarely
Sometimes
Often
Very often
How many hours of sleep do you usually get per night?
Less than 5
5-6
7-8
9-10
More than 10
Prefer not to say
Do you currently smoke or vape?
Never
Former
Occasionally
Daily
Prefer not to say
In a typical week, how many alcoholic drinks do you have?
0
1-3
4-7
8-14
15+
Prefer not to say
How often do you eat 5 or more servings of fruits and vegetables per day?
Very rarely
Rarely
Sometimes
Often
Very often
How would you rate your overall health right now?
Poor
Below average
Average
Good
Exceptional
Are you experiencing any current symptoms or health concerns you want to mention?
What is your pain level today?
None
Mild
Moderate
Severe
Very severe
Over the past 2 weeks, how often have you felt down, depressed, or hopeless?
Never
Rarely
Sometimes
Often
Always
Over the past 2 weeks, how often have you felt nervous, anxious, or on edge?
Never
Rarely
Sometimes
Often
Always
What is your top health goal for the next 3 months?
May we contact you by email regarding your responses?
Yes
No
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Paper art illustration depicting a self-health assessment form with various health-related elements and design features

When to use this form

Use this form when you want a quick, structured check of your current health before a clinic visit, telehealth chat, or starting a wellness plan. It helps students, employees, caregivers, and individuals track symptoms, habits, and risks in one place. Complete it after a new diagnosis, before travel, or when a change in mood, sleep, or energy lasts more than a few days. If you want a broader list to review, pair it with the Health checklist form. To capture eating patterns that affect weight, blood sugar, or GI symptoms, log meals alongside the Food diary form. The result is a clear snapshot you can share, compare over time, and use to decide next steps.

Must Ask Self-Health Assessment Questions

  1. What symptoms are you experiencing, and when did they start?

    Timeline and specifics help you spot patterns, gauge severity, and decide if you need urgent care or self-care. For a deeper risk review, you can also use the Health risk assessment questionnaire form.

  2. Do you have any chronic conditions or recent diagnoses?

    Existing conditions change how you interpret new symptoms and which next steps make sense. This context helps you prioritize follow-ups and avoid conflicting advice.

  3. Which medications, supplements, or medical devices are you using right now?

    Listing names and doses prevents interactions and explains side effects that mimic illness. It also improves coordination with your clinician or care team.

  4. Do your symptoms limit work, school, or daily activities?

    Functional limits show impact and urgency, guiding care plans and accommodations. If needed, document specific work limits with the Functional capacity evaluation form.

  5. Do you have any allergies, and what reactions have you had?

    Allergy details keep you safe from triggers and inform medication choices. If you need a plan for exposures, see the Allergy action plan form.

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