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Free Health Questionnaire Template

Free Health Questionnaire

Health Questionnaire

Health Questionnaire

Please complete this form honestly.

Personal Information

Name

Please enter your full name as it appears on your official documents.

Date of Birth

Enter your date of birth in MM-DD-YYYY format.

Email

Please provide your email address to receive updates regarding your health assessments.

Emergency Contact Name

Please enter your full name as it appears on your official documents.

Emergency Contact Number

Enter your primary phone number with your country code.

General Health Information

How would you describe your overall health?

Excellent
Good
Fair
Poor

Do you have any known allergies?

If yes, please specify.

Are you currently taking any medications?

If yes, please specify.

Lifestyle & Medical History

Do you smoke?

Yes
No

Do you consume alcohol?

Yes, regularly
Occasionally

Have you had any recent surgeries or hospitalizations?

If yes, please specify.

Do you have any additional health concerns or symptoms?

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