Free Health Assessment Form HR Template
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.
