Medical Assessment Form
Medical Assessment Form
Please fill out this form to provide your medical history and current health status.
Personal Information
Name
Date of Birth
Address
Phone number
Medical History
Do you have any known allergies?
If yes, please specify
Do you have any chronic conditions or illnesses?
If yes, please specify
Are you currently taking any medications?
If yes, please specify
Have you had any surgeries in the past?
If yes, please specify
Current Health Status
Are you experiencing any symptoms or concerns?
If yes, please specify
Do you use tobacco, alcohol, or recreational drugs?
If yes, please specify
Are you pregnant or planning to become pregnant? (For women)
If yes, please specify
Emergency Contact
Name
Phone number
Relationship
Signature
I certify that the information provided above is accurate to the best of my knowledge.
Name:
Date:
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