Health Questionnaire Template
Download
Health Questionnaire
Please complete this form honestly.
Personal Information
Name
Please enter your full name as it appears on your official documents.
Date of Birth
Enter your date of birth in MM-DD-YYYY format.
Please provide your email address to receive updates regarding your health assessments.
Emergency Contact Name
Please enter your full name as it appears on your official documents.
Emergency Contact Number
Enter your primary phone number with your country code.
General Health Information
How would you describe your overall health?
Excellent
Good
Fair
Poor
Do you have any known allergies?
If yes, please specify.
Are you currently taking any medications?
If yes, please specify.
Lifestyle & Medical History
Do you smoke?
Yes
No
Do you consume alcohol?
Yes, regularly
Occasionally
Have you had any recent surgeries or hospitalizations?
If yes, please specify.
Do you have any additional health concerns or symptoms?
Thank you for Completing this Form!
Your information helps us ensure your well-being!
Create free forms at Template.net
Templates
Templates
