General Health Appraisal Form

Name

First NameLast Name

Date of Birth

Date

Gender

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current Medications

List any medications you are currently taking, including dosage.

Allergies

List any known allergies to medications, foods, or environmental factors.

Chronic Conditions

Indicate any chronic medical conditions you have been diagnosed with (e.g., diabetes, hypertension, asthma).

Previous Surgeries

List any surgeries you have undergone, including the date and type of surgery.

Dietary Habits

Describe your typical daily diet, including any dietary restrictions.

Physical Activity

How often do you engage in physical activity, and what types of activities do you enjoy?

Sleep Patterns

Describe your typical sleep duration and quality.

Substance Use

Do you smoke? How often? Do you consume alcohol or recreational drugs? Specify amounts and frequencies.

Stress Levels (How would you rate your stress levels on a scale from 1 to 10?)

Have you ever been diagnosed with a mental health condition? If yes, please provide details.

YesNo

Please specify which vaccines you may be missing:

List any routine health screenings you have undergone recently (e.g., mammogram, cholesterol test, colonoscopy).

Describe your current occupation and any potential occupational hazards.

Do you have significant exposures to environmental factors (e.g., chemicals, pollutants) in your daily life?

What specific health goals would you like to achieve in the next six months?

Outline any long-term health goals or aspirations.

Declaration:

I, the undersigned, declare that the information provided in this General Health Appraisal Form is accurate to the best of my knowledge.

Date

Signature

General Health Appraisal Form

Personal Information

Medical History

Lifestyle Factors

Mental and Emotional Health

Preventive Health Practices

Occupational and Environmental Factors

Health Goals