Free Health Assessment Form Template
Health Assessment Form
Please fill out this form with complete details.
Date
Personal Information
Name
Gender
-
Male
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Female
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Date of Birth
Phone Number
Health Information
Do you have any chronic conditions, allergies, or taking any medications?
If yes, please specify
Have you had any recent surgeries or hospitalizations?
How often do you engage in physical activity?
Do you smoke or use tobacco products?
Do you consume alcohol?
Current Health Concerns
Please describe any symptoms or concerns you are currently experiencing:
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