Health Report Form
A registered physician or medical consultant prepares health report form. The purpose of this report form is to provide adequate health and fitness related information of an individual. It is a comprehensive report that consist the medical history of a person and present health status.
Sample Health Report Form
General Information
Name of Patient_____________ Age_____ Sex_______
Address___________ Phone_________ Email___________
Social Security Number___________
Physician Name____________ Address____________ Phone________
Health Report Information
Report prepared by______________
History of Illness and Dieses until date_____________
______________
_______________
Blood Group__________ Eye Sight__________
Height__________ Weight___________
Does the patient have any family history of any chronic dieses/heart trouble/diabetes____________
In past, does the person have gone through any surgery __________________
List the allergies, if any________________
List the physical disabilities with details, if any__________________________
List the mental disabilities in details, if any_____________________________
Is the person taking any medical treatment/prescription, if yes than provide details____________________________
List the past medical treatments/operations_______________
Signature____________ Date of report submission___________
Report Submitted to___________
Category: Report Forms

