Health Assessment Form HR

Health Assessment Form

This form is designed to gather essential information about your health and medical history to ensure that you receive the best possible care.

Patient Information:

Name	[Your Name]
Date Of Birth	January 1, 1985
Gender	Male
Address	123 Main Street, Anytown, USA
Phone Number	(555) 123-4567

Medical History:

Please list any medical conditions you have:

Hypertension and Allergic Rhinitis

Are you currently taking any medications?

[X] Yes [ ] No

If yes, please list them: Lisinopril (10mg daily) and Loratadine (10mg as needed)

Have you ever had surgery?

[ ] Yes [X] No

If yes, please provide details: N/A

Family Medical History:

Are there any significant medical conditions that run in your family?

[X] Yes [ ] No

If yes, please specify: Diabetes (mother) and Heart Disease (father)

Current Health:

Do you have any current symptoms or health concerns?	[X] Yes [ ] No If yes, please describe them: Occasional Headaches and Fatigue
Have you experienced any recent weight changes?	[X] Yes [ ] No If yes, please provide details: Gradual weight gain of 5 lbs over the past 3 months
Do you smoke?	[ ] Yes [X] No If yes, how many cigarettes per day: N/A
Do you consume alcohol?	[X] Yes [ ] No If yes, how many alcoholic drinks per week: 2-3 drinks per week
How would you describe your typical diet? (e.g., balanced, vegetarian, fast food)	Balanced diet with plenty of fruits and vegetables
Do you engage in regular physical activity?	[X] Yes [ ] No If yes, please describe your exercise routine: 30 minutes of brisk walking 5 days a week

Additional Information:

Are you currently pregnant or planning to become pregnant?

[ ] Yes [X] No

If yes, please specify: N/A

Are you allergic to any medications or substances?

[X] Yes [ ] No

If yes, please list them: Penicillin and Bee stings

Blood Pressure And Vital Signs:

Blood Pressure	130/80 mm Hg
Heart Rate	72 beats per minute
Respiratory Rate	16 breaths per minute
Height	5 feet 10 inches
Weight	180 pounds

Provider's Notes:

Provider's Name	Dr. Emily Johnson
Date Of Assessment	September 27, 2050

Assessment Findings And Recommendations:

Patient report occasional headaches and fatigue. Blood pressure is within the normal range but slightly elevated. Advised patient to monitor blood pressure at home regularly and consider stress-reduction techniques. Recommended annual check-up and encouraged a balanced diet and regular exercise routine to maintain overall health.