Free Healthcare Client Information Sheet Template

Healthcare Client Information Sheet

I. Personal Information

Full Name:

Emie Howell

Date of Birth:

July 11, 2050

Gender:

  • Male

  • Female

  • Other

Address:

Albuquerque, NM 87101

Phone Number:

222 555 7777

Email Address:

emie@you.mail

II. Emergency Contact Information

Please provide details of someone we can contact in case of an emergency.

Contact Name:

Kid Howell

Relationship:

Spouse

Contact Number:

222 555 7777

III. Medical History

Provide details of any medical conditions you have or have had in the past.

Do you have any chronic illnesses? If yes, please specify.

  • Yes

  • No

Condition: Hypertension

Do you have any known allergies? If yes, please specify.

  • Yes

  • No

Allergies: Penicillin, Shellfish

List any medications currently being taken

  • Lisinopril (10 mg, once daily)

  • Omega-3 Supplements

IV. Insurance Information

Insurance Provider:

SecureHealth Advantage

Policy Number:

SH-2080-EM-12345

Group Number (if applicable):

GRP-56789

Please ensure that all the information provided is accurate and up-to-date to assist with your healthcare needs.

If you have any questions or need to make updates, please contact [YOUR COMPANY NAME] at [YOUR COMPANY NUMBER].

Sheet Templates @ Template.net