This printable comprehensive health assessment form gives clinics, general practices, and occupational health teams a seven-page questionnaire that captures a complete picture of a patient's health in a single sitting. It moves from personal details through lifestyle habits, medical and family history, current symptoms, and mental wellbeing, and closes with a signed consent declaration.
What this survey measures
The form opens with identification and contact details, then screens smoking, alcohol, exercise, and sleep alongside a six-item daily habits grid. A twelve-condition medical history checklist and an eight-condition family history screen flag risk factors, with open boxes for medications, supplements, and allergies in the patient's own words. A ten-symptom severity grid records what is bothering the patient right now, and a seven-item mental wellbeing scale with an overall wellbeing rating rounds out the clinical picture.
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.