Health Assessment

Name

First NameLast Name

Date of birth

Date

Gender

MaleFemaleOther

Emergency Contact Name

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.

Do you have any chronic illnesses or medical conditions? (e.g., diabetes, hypertension)

YesNo

If yes, please specify

Have you had any surgeries or hospitalizations in the past?

YesNo

If yes, please provide details

Are you currently taking any medications?

YesNo

If yes, please list them

Do you have any allergies? (e.g., food, medication, environmental)

YesNo

If yes, please specify

Do you smoke?

YesNo

If yes, how many cigarettes per day

Do you consume alcohol?

YesNo

If yes, how often and how much

Do you use recreational drugs?

YesNo

If yes, please specify

Describe your diet

How often do you exercise?

Do any of your close relatives have any of the following conditions?

Are you currently experiencing any of the following symptoms? (Check all that apply)

Do you have any other health concerns or symptoms not listed above?

YesNo

If yes, please specify

How would you describe your current mental health status?

Are you currently experiencing any of the following? (Check all that apply)

Have you ever been diagnosed with a mental health condition?

YesNo

If yes, please specify

Do you have any other health-related information you would like to share?

Consent

By signing below, I acknowledge that the information provided is accurate to the best of my knowledge and I consent to its use for the purpose of my health assessment.

Signature

Date Signed

Date

Health Assessment Form