Home
Templates
Form
Assessment Form
Free Health Assessment Form Template

Free Health Assessment Form

Name: Free Health Assessment Form Template
Brand: Template.net
Availability: InStock

Health Assessment Form

Please complete this form with accurate and up-to-date information.

Personal Information

Name

Date of Birth

Sex

Male
Female

Phone number

Email

Emergency Contact Information

Name

Relationship

Phone number

Lifestyle Information

Diet Description

Vegetarian
Pescatarian
Keto
Low-Carb
Option 5

Do you follow a regular sleep schedule?

How often do you engage in physical exercise?

How often do you consume alcohol?

How often do you smoke or use tobacco products?

Do you use recreational drugs?

Medical and Health Information

Have you ever been diagnosed with any chronic illnesses? (e.g., diabetes, hypertension, etc.)

Do you have any known allergies?

Are you currently taking prescribed medications?

Have you undergone any surgeries in the past?

Do any of your family have any of the following conditions?

Check all that apply:

Heart Disease
Diabetes
Cancer
Hypertension
Stroke
Mental Health Conditions
None

Do you currently suffer from the following?

Check all that apply:

Headaches
Dizziness
Shortness of Breath
Chest Pain
Fatigue
Joint Pain
Nausea
None

Have you ever been diagnosed with a mental health condition?

Are you currently experiencing any of the following?

Check all that apply:

Persistent Sadness
Anxiety
Insomnia
Low Energy/Fatigue
Mood Swings
Difficulty Concentrating
Loss of Interest in Activities
Social Withdrawal
None

Current Mental Health Status

Additional Information

Indicate any additional health concerns that you would like to share:

Acknowledgement

I hereby confirm that the information provided in this form is accurate and complete to the best of my knowledge. I understand that this information will be used to assess my health.

Name:

Date:

Assessment Form Templates @ Template.net

Thank you for submission!

We appreciate you taking the time to submit.

Create free forms at Template.net

Free

Edit this free template

No sign up needed

100% Customizable, free editor
Access 1 Million+ Templates, photo’s & graphics
Download or share as a template
Click and replace photos, graphics, text, backgrounds
Resize, crop, AI write & more
Access advanced editor

Ensure tailored health evaluations with the Health Assessment Form Template provided by Template.net! This template's customizable fields allow you to document patient details and current health concerns effectively. It is editable to suit various healthcare settings, from clinics to corporate wellness programs. With the AI Editor Tool, easily tailor the form to meet your organization's unique requirements!