The Health Risk Assessment Form Template by WPForms is a helpful tool designed for hospitals, medical clinics, and institutions that allows doctors and nurses to provide their patients with a detailed health risk assessment report.
How Does the Health Risk Assessment Form Template Work?
The Health Risk Assessment Form Template requires the WPForms Basic License since it uses numerous Fancy Fields to gather and collect information in an improved manner. Here is a brief overview of the fields include:
- Patient Information:
- Full Name: Identifies the individual taking the assessment.
- Date of Birth: Crucial for age-related health analysis.
- Age: Automatically calculated or entered for demographic data.
- Gender: Important for tailored health recommendations.
- Email Address: For sending assessment results and follow-up information.
- Phone Number: Essential for direct communication or urgent updates.
- Emergency Contact Name: A safety measure for immediate outreach
- Emergency Contact Number: Direct line to someone who can assist in emergencies.
- Address: Useful for regional health advisories or in-person follow-ups.
- Reason for Visit: Helps focus the assessment on specific health concerns.
- Past Medical History (PMH):
- Chronic Illnesses: Tracks ongoing health conditions.
- Surgeries: Records past surgical procedures for a complete medical history.
- Medications: Lists current medications for drug interaction checks.
- Allergies: Notes any allergies, especially critical for medication and food.
- Family Illness History:
- Family History:
- Mother: Captures genetic health patterns of the mother.
- Father: Records genetic health patterns of the father.
- Siblings: Any illnesses or sicknesses of siblings in the family.
- Social History:
- Occupation: Provides context for occupational health risks.
- Tobacco Use: Assesses risk related to smoking habits.
- Alcohol Use: Evaluates potential health risks from alcohol consumption.
- Recreational Drugs: Inquires about non-prescription drug use.
- Diet: Understands nutritional intake and dietary habits.
- Exercise: Gauges physical activity levels.
- Review of Systems (ROS):
- Checklists: Comprehensive checklist covering various body systems for:
- Respiratory
- Neurological
- Endocrine
- Genitourinary
- Musculoskeletal
- Dermatological
- Psychiatric
- Cardiovascular
- Checklists: Comprehensive checklist covering various body systems for:
- Physical Examination:
- Blood Pressure: Vital sign indicating cardiovascular health.
- Heart Rate: Measures pulse rate as a basic health indicator.
- Temperature: Checks for fever or abnormal body temperature.
- Respiratory Rate: Assesses breathing rate and function.
- General Appearance: Observational notes on physical state and alertness.
- Assessment & Plan:
- Paragraph Text: Concluding section for healthcare provider’s notes and recommendations.
Sign up with WPForms today and access the Health Risk Assessment Form Template. It is perfect for healthcare providers, wellness coaches, and community leaders aiming to foster a healthier environment for their patients.
