Comprehensive Health Assessment Template

Comprehensive health assessment form with 63 questions covering medical history, medicines, family history, symptoms, lifestyle, mental wellbeing, and consent.

Questions: 63EnglishHealthcare and Care Homes

Print this ready-made questionnaire and hand it out, then scan and upload the completed forms to read the answers automatically. You can also share the same questionnaire online. The preview below shows the paper version.

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This printable comprehensive health assessment form gives clinics, general practices, and occupational health teams an eight-page adult health questionnaire that captures a complete picture of a patient's health in a single sitting. Across 63 questions it moves from personal details and emergency contacts through general health, medical history, medicines and allergies, family history, current symptoms, lifestyle, and mental wellbeing, and closes with health goals and a signed consent declaration.

What this survey measures

The form opens with identification, contact, and emergency contact details, then records general health, the reason for the visit, height, and weight. A sixteen-condition medical history checklist, past operations, routine health checks, and vaccinations build the clinical history. The medicines section lists prescriptions, over-the-counter products, adherence, allergies, and side effects. A family history grid records which relatives had each condition. Current symptoms are rated for severity, alongside a pain score and a short daily functioning grid. The lifestyle section covers tobacco, vaping, alcohol, activity, sleep, and diet, and the mental wellbeing section asks about mood, stress, and whether the patient would like support. Patients finish by choosing the areas they want help with, adding anything else their care team should know, and signing the consent declaration.

How to use it on paper

Hand the form to new patients at registration, mail it ahead of an appointment, or use it for annual reviews and occupational health checks. Patients mark the checkboxes with a blue or black pen, write in the open fields, then sign and date the consent section. Scan the completed forms in batches: PaperSurvey reads the marked answers with optical mark recognition and converts the handwritten fields to text automatically, so every assessment reaches your dashboard without manual data entry.

Customize this template

Add your clinic logo, adjust the condition lists to match your specialty, or extend the symptom grid with items relevant to your patient population. The paper layout reflows automatically as you edit, and every copy you print stays scannable.

Preview the PDF above, or use this template to start collecting health assessments today.

Paper and web from one template

Use this questionnaire on paper, online, or both, and collect all responses in one place. Preview it as a web survey Open it in a new tab. This is a preview only. Responses are not saved.

Questions in this template

Full name
Date of birth
Gender
Home address
**Health card or insurance number**
**Occupation**
**Phone number**
**Email address**
What is your current work situation?
Do you need an interpreter at your appointments?
Emergency contact name
**Relationship to you**
**Their phone number**
Your usual doctor or GP practice
How would you prefer us to contact you about your care?
In general, how would you rate your health?
What is the main reason for this assessment?
How long ago did you last see a doctor?
**Height in cm**
**Weight in kg**
What are your main health concerns at the moment?
Have you ever been diagnosed with any of the following?
Please list any other conditions you have been diagnosed with
Please list any operations or hospital stays, with the year
When did you last have each of these health checks?
Which vaccinations have you had in the last 10 years?
Do you take any prescription medicines regularly?
Please list all the medicines you take, with the dose and how often
Which of these do you take without a prescription?
How often do you forget to take your medicines?
Are you allergic to any of the following?
Please describe each allergy and the reaction you had
Do you carry an adrenaline auto-injector?
Have you ever had a bad side effect from a medicine?
Who usually manages your medicines?
Name of your usual pharmacy
Which of your blood relatives have had the following conditions?
For any condition marked above, please note the relative and their age at diagnosis
Are your parents still living?
How much do you know about your family's medical history?
Has a close relative died suddenly or unexpectedly before the age of 50?
Has anyone in your family been diagnosed with an inherited condition?
In the past month, how much have these symptoms bothered you?
Approximately when did your main symptom begin?
How would you rate your pain on average over the past week?
Do you have difficulty with any of the following?
Do you smoke or use tobacco?
Do you vape or use electronic cigarettes?
How often do you have a drink containing alcohol?
On a day when you drink, how many drinks do you usually have?
On how many days a week are you active for 30 minutes or more?
How many hours do you usually sleep each night?
How often do these apply to you?
Over the past two weeks, how often have you experienced the following?
Overall, how would you rate your wellbeing today?
How well are you coping with stress at the moment?
Would you like to talk to someone about your mental health?
Which areas would you most like help with?
How ready do you feel to make changes to your health?
Is there anything else you would like your care team to know?
May we share this information with others involved in your care?
Patient signature
Date signed

What this survey measures

How to use it on paper

Customize this template

Paper and web from one template

Questions in this template

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