Free Simple Check-Up Checklist Template
Check-Up Checklist
Personal Information
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Name: Ena Cassin
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Email: ena@you.mail
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Company Name: BluCurrent
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Company Address: Louisville, KY 40201
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Company Email: inquire@blucurrent.mail
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Company Number: 222 555 7777
General Information
|
Item |
Date Completed |
Notes |
|---|---|---|
|
January 15, 2050 |
Appointment scheduled for 10:00 AM |
|
January 15, 2050 |
Confirm allergies and past surgeries |
|
January 15, 2050 |
List current medications |
|
January 15, 2050 |
Confirm details are accurate |
Physical Examination
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Blood Pressure Measurement
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Weight and Height Check
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Heart Rate Monitoring
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Body Mass Index (BMI)
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Skin Check for unusual marks or growths
Laboratory Tests
|
Test Name |
Scheduled Date |
Results Date |
|---|---|---|
|
January 16, 2050 |
January 18, 2050 |
|
January 16, 2050 |
January 18, 2050 |
|
January 16, 2050 |
January 18, 2050 |
Immunization Check
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Review vaccination records
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Schedule any missing vaccines
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Flu shot (if applicable)
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Covid-19 booster (if applicable)
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Other required vaccines (e.g., Hepatitis B, Tdap)
Screening Tests
|
Test Name |
Date Scheduled |
|---|---|
|
February 20, 2050 |
|
February 20, 2050 |
|
February 20, 2050 |
Follow-Up and Recommendations
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Discuss test results with healthcare provider
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Schedule follow-up appointments if necessary
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Review lifestyle changes (diet, exercise, sleep)
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Obtain a copy of the check-up summary
Next Steps
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Book Next Appointment: Schedule the next annual check-up by January 2025.
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Stay on Track: Follow up with your healthcare provider for any test results or further actions needed.
If you haven’t scheduled your annual health check-up, take the first step today! Contact [YOUR COMPANY NAME] at [YOUR COMPANY NUMBER] or email [YOUR COMPANY EMAIL] to schedule your appointment. Your health is important, and staying proactive helps you live better and longer.
