Free Health Assessment Checklist Template
Health Assessment Checklist
Section 1: Personal Information
|
Field |
Details |
|---|---|
|
Name |
Jarvis White |
|
|
jarvis@you.mail |
|
Company Name |
BluWave |
|
Company Address |
Salt Lake City, UT 84101 |
|
Contact Number |
222 555 7777 |
Section 2: Physical Health Checklist
|
Assess |
Target Range |
Status |
Notes |
|---|---|---|---|
|
120/80 mmHg |
125/85 mmHg |
Slightly Elevated |
|
18.5–24.9 |
23.5 |
Healthy |
|
60–100 bpm |
72 bpm |
Normal |
|
< 200 mg/dL |
190 mg/dL |
Normal |
|
< 140 mg/dL (fasting) |
110 mg/dL |
Healthy |
Section 3: Mental Health and Lifestyle
|
Question |
Response |
|---|---|
|
Yes |
|
7–8 hours |
|
Yes |
|
No |
|
3 servings |
Section 4: Follow-Up Actions
-
Schedule an appointment for a detailed physical examination by June 15, 2050.
-
Enroll in a wellness program or corporate fitness plan by July 1, 2050.
-
Address any concerns noted in the checklist with a health provider before August 10, 2050.
Take control of your health today! Complete this checklist and reach out to us at [YOUR COMPANY EMAIL] or call [YOUR COMPANY NUMBER]. Together, we can design a personalized plan to help you achieve optimal health by 2050 and beyond!
