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.

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