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Statement of Health Form Template

Effortlessly Create Your Statement of Health

Completing a health statement can feel overwhelming, especially when accurate information is crucial. This Statement of Health Form Template is designed for anyone needing to provide a clear and accurate account of their health status, ideal for insurance applications or medical assessments. By using this template, you can streamline the process, ensure your information is organized, maintain compliance with health guidelines, and effortlessly share data with healthcare providers. Try out the live template to simplify your documentation.

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Full name
Date of birth
Email address
Phone number
Residential address
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Primary care physician or clinic name
Are you currently under the care of a physician or clinic?
Yes
No
How would you rate your general health?
Poor
Below average
Average
Good
Exceptional
Height (include units)
Weight (include units)
Do you have, or have you ever had, any of the following conditions? (Select all that apply)
Have you had any surgeries or hospitalizations in the past 5 years?
Yes
No
If yes, please list surgeries or hospitalizations and dates
Current medications and supplements (name, dose, frequency)
Please describe allergy details and reactions
Allergies
No known allergies
Medications
Foods
Latex
Environmental (pollen, dust, etc.)
Insect stings
Other
Please Specify:
Tobacco or nicotine use
Never
Former
Occasional
Daily
Prefer not to say
Alcohol use
Never
Rarely
Sometimes
Often
Prefer not to say
Recreational drug use
Never
Past use
Occasional
Regular
Prefer not to say
Are your immunizations up to date?
Yes
No
Unsure
Are you currently pregnant?
Yes
No
Not applicable
Prefer not to say
Additional health concerns you wish to report
In the past 30 days, have you experienced any of the following? (Select all that apply)
Please Specify:
I declare that the information provided in this statement is true and complete to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Full legal name (serves as signature)
Date of signature
I authorize the release of this statement of health to the requesting organization for the stated purpose.
Yes
No
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Paper art illustration depicting a health form and design elements for a Statement of Health article

When to use this form

Use this form any time you need a verified snapshot of someone's current health for enrollment, travel, or workplace safety. HR teams can document conditions, medications, and emergency contacts before a start date. Coaches, camp directors, and fitness centers can confirm readiness for physical activity and set safe limits. Clinics and insurers can check for changes before a procedure or application to reduce delays. If someone reports allergies, pair the submission with the Allergy action plan form to record triggers and steps to take. For routine self-checks, the Health checklist form keeps preventive items on track. When monitoring hypertension, invite a Home blood pressure report form alongside this health statement to give context.

Must Ask Statement of Health Questions

  1. Which medical conditions have you been diagnosed with, and when were they last evaluated?

    This helps you identify risks, needed accommodations, and eligibility for programs or coverage. Dates show stability or progression, so you can plan follow-up or request documentation.

  2. What medications, supplements, or medical devices do you use, including dosage and frequency?

    Clear lists prevent dangerous interactions and support safe activity or treatment plans. Dosage and schedule details let you coordinate timing and verify compliance.

  3. Do you have any allergies or sensitivities, and what reactions do you experience?

    Knowing triggers and severity guides prevention and emergency response. It also tells staff what to avoid and when to keep epinephrine or other meds on hand.

  4. Have you had any recent symptoms, hospitalizations, or surgeries in the past 12 months?

    Recent events reveal current risk and whether a statement of good health is appropriate. This helps you decide if medical clearance or extra monitoring is needed.

  5. What lifestyle factors may affect your health today, such as tobacco use, alcohol, diet, sleep, or exercise?

    Context makes recommendations more relevant and supports behavior change. If you track eating patterns, you can pair responses with a Diet journal form for added detail.

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