Health Assessment Form

Build a complete clinical picture at first contact: conditions, surgeries, medication, allergies, lifestyle, family history and mental wellbeing. Follow-up prompts appear only when the patient answers yes, keeping the form short. It closes with a dated signature for the record.

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Full name

Nombre

Apellido

Date of birth

Gender

Female Male Non-binary Prefer not to say

Emergency contact name

Nombre

Apellido

Relationship

Phone number

Do you have any chronic illness or medical condition (for example diabetes or hypertension)?

Yes No

If yes, please specify

Have you had any surgery or hospital stay in the past?

Yes No

If yes, please provide details

Are you currently taking any medication?

Yes No

If yes, please list them

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

Yes No

If yes, please specify

Do you smoke?

Yes No Former smoker

If yes, how many cigarettes a day?

Do you drink alcohol?

Yes, regularly Occasionally No

If yes, how often and how much?

Do you use recreational drugs?

Yes No Prefer not to answer

If yes, please specify

Describe your diet

Balanced and varied Vegetarian Vegan Low carbohydrate Gluten free High protein Mostly processed food

How often do you exercise?

Do any close relatives have any of these conditions?

Are you experiencing any of these symptoms right now? Select all that apply.

Do you have other concerns or symptoms not listed above?

Yes No

If yes, please specify

Are you currently going through any of the following? Select all that apply.

Have you ever been diagnosed with a mental health condition?

Yes No Prefer not to answer

If yes, please specify

Is there anything else about your health you would like to share?

Patient declaration

Signature

Sign here

Date signed

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