Medical Assessment Form
PERSONAL INFORMATION
Full Name
*
Gender
*
Please Select
Male
Female
Not willing to Disclose
Date of Birth
*
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Day
Please select a month
January
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Month
Please select a year
2026
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Year
Address
*
Street Address
City
Have you been vaccinated for Covid-19?
*
Yes
No
What vaccine?
Pfizer- BioNTech
Oxford- AztraZeneca
CoronaVac- SinoVac
Johnson and Johnson's- Janssen'
Gamelaya- Sputnik
Moderna
When did you get your 1st shot?
Date
. Your 2nd shot?
Date
Have you had any direct contact with a confirmed case of Covid-19?
Yes
No
If Yes, how many times have you been exposed to Covid-19 Positive cases?
Other
Where did you get your exposure to Covid-19 from?
Family Member
Relative
Workmates
Friends
Have you been tested positive for Covid-19?
Back
Next
PERSONAL MEDICAL HISTORY
ALLERGY:
Foods, medications or dust
ALLERGIC REACTION:
DISEASE/CONDITION:
Rows
Current
Past
Date Diagnosed, Experienced Symptoms, Treatment
Asthma
1
2
Cancer (Type)
3
4
Diabetes (Type)
5
6
High Blood Pressure (Hypertension)
7
8
Heart Disease
9
10
Renal/Kidney Disease
11
12
Migraine Headaches
13
14
High Cholesterol
15
16
Other:
17
18
Other Minor Health Complaints (e.g Headache, Back Pain)
SURGERIES:
Rows
Type(Specify Left or Right)
Date of Surgery
Location/Facility
1
2
3
MEDICATIONS:
Rows
Medications
Dose(how many milligram)
Times Per Day
1
2
3
MENTAL HEALTH
In the past 4 weeks,
Rows
None of the time
A little of the time
Some of the time
Most of the time
All of the time
1. How often did you feel tired for no good reason?
19
20
21
22
23
2. How often did you feel nervous?
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26
27
28
3. How often did you feel so nervous that nothing can calm you down?
29
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33
4. How often did you feel hopeless?
34
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38
5. How often did you feel restless?
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43
6. How often did you feel so restless that you could not sit still?
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48
7. How often did you feel depressed?
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8. How often did you feel that everything was an effort?
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9. How often did you feel so sad that nothing could cheer you up?
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10. How often did you feel that you're worthless?
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68
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