Health Assessment Form

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:

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