Health Assessment Form
Health Assessment Form
Please complete this form with accurate and up-to-date information.
Personal Information
Name
Date of Birth
Sex
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Male
-
Female
Phone number
Emergency Contact Information
Name
Relationship
Phone number
Lifestyle Information
Diet Description
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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:
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Heart Disease
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Diabetes
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Cancer
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Hypertension
-
Stroke
-
Mental Health Conditions
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None
Do you currently suffer from the following?
Check all that apply:
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Headaches
-
Dizziness
-
Shortness of Breath
-
Chest Pain
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Fatigue
-
Joint Pain
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Nausea
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None
Have you ever been diagnosed with a mental health condition?
Are you currently experiencing any of the following?
Check all that apply:
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Persistent Sadness
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Anxiety
-
Insomnia
-
Low Energy/Fatigue
-
Mood Swings
-
Difficulty Concentrating
-
Loss of Interest in Activities
-
Social Withdrawal
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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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