A health assessment form is filled in both official and domestic settings to determine the health fitness of an individual. Although the form does not go into detail health checkup, it enables the establishment of the person’s health status and can be used when applying for insurance, a job, school etc.  Here is a sample health assessment form.

Heath Assessment Form

Name: _____________________________ Date of Birth: ___________________

Gender: _____________________  Employee No. ________ Position: _________

Street Address: _______________ City: ___________ State: ___________ Zip: _______

Telephone: ______________ Email: ________________ Fax: __________________

I. Medical conditions

Please indicate TRUE or FALSE in the spaces to the right of the statement

Heart Failure    ___________ Hypertension   ___________

Angina     ___________ Hypercholesterolemia ___________

Emphysema    ___________ Asthma   ___________

Allergic rhinitis   ___________ Diabetes   ___________

Thyroid disease   ___________ Esophagitis   ___________

Duodenal, stomach or Peptic ulcer ___________ Glaucoma   ___________

Colitis and Crohn’s disease  ___________ Seizures   ___________

Peripheral vascular   ___________ Blood clot problems  ___________

Benign prostatic hyperplasia  ___________ Arthritis   ___________

Osteoporosis    ___________ Depression   ___________

Migraine headaches   ___________ Other (Specify)  ___________

Section II: Drug Allergy Conditions

Indicate TRUE for allergic and FALSE for not allergic

Cephalosporin Antibiotics and Penicillin  _______________________

Tetracycline antibiotics    _______________________

Erythromycin      _______________________

Codeine      _______________________

Non-steroidal anti-inflammatory drugs (NSAID) _______________________

Ibuprofen      _______________________

Aspirin       _______________________

Sulfa drugs      _______________________

Iodine       _______________________

Other unlisted ALLERGIC drugs   _______________________

Notes and comments

___________________________________________________________________________________________________________________________________________________________________________________________________________________________

Assessment Checked by: ________________________ Position: ____________________

Signature: ___________________________________ Date: _______________________

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