Templates Health & Wellness Medical Health Screening Consent Form Template

Health Screening Consent Form Template

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Patient Information

Full Name
Residential Address

Past Medical History (PMH)

Review of Systems (ROS)

Patients are often asked to check any symptoms they currently have or have had in the last 6-12 months.


Consent and Acknowledgment

Consent to Proceed
Privacy Acknowledgment
Clear Signature

The Health Screening Consent Form Template by WPForms helps any organization or healthcare provider looking to organize health screenings efficiently.

How Does the Health Screening Consent Form Template Work?

The Health Screening Consent Form Template requires the WPForms Pro License and the Signature Addon to collect patient information and appropriate consent. Fields include:

  • Patient Information:
    • Name: Records the full name of the individual undergoing the health screening.
    • Gender: Captures the gender of the person to tailor health screening.
    • Date of Birth: Critical for age-related health risks and screening requirements.
    • Email Address: For sending health screening results and follow-up information.
    • Phone Number: Essential for urgent communication or clarification.
    • Residential Address: Useful for sending detailed reports or additional resources.
  • Past Medical History (PMH):
    • Reason for Visit: Helps prioritize screening based on the individual’s concerns.
    • Chronic Illnesses: Important for understanding existing health conditions.
    • Surgeries: Provides insight into past medical interventions.
    • Medications: Assists in identifying potential interactions or contraindications.
    • Allergies: Crucial for avoiding allergic reactions during the screening process.
  • Review of Systems:
    • Comprehensive Checklists: Detailed overview of bodily systems to identify areas requiring special attention during the screening.
  • Consent and Acknowledgment:
    • Consent to Proceed: Necessary for proceeding with health screenings.
    • Privacy Acknowledgment: Ensures the individual acknowledges their rights.
    • Signature and Date: Confirms the individual’s agreement to the screening terms.

Sign up with WPForms today and access the Health Screening Consent Form Template. It is ideal for clinics, hospitals, health fairs, and any entity organizing health screenings.