Templates Health & Wellness Medical Men’s Health Check Form Template

Men’s Health Check Form Template

Use This Template
Please enable JavaScript in your browser to complete this form.

Personal Information

Health History

Lifestyle Information

Health-Specific Information

Consent and Acknowledgment

Clear Signature

The Men’s Health Check Form Template by WPForms is a great tool for any program. community, or organization that wants to simplify the journey toward comprehensive health assessments tailored for men.

How Does the Men’s Health Check Form Template Work?

The Men’s Health Check Form Template requires the WPForms Pro License and the Signature Addon to collect vital health information from the men participating in a program. Here’s a snapshot of the fields you’ll find in the template:

  • Personal Information:
    • Full Name: The participant’s complete name for personal identification.
    • Date of Birth: To calculate age, which is crucial for certain health screenings.
    • Email Address: For sending health reports or follow-up information.
    • Contact Number: Essential for direct communication or urgent updates.
  • Health History:
    • Current Medications: Information on any medications being taken.
    • Allergies (if any): To note any allergies, particularly relevant in a medical setting.
    • Past Medical History: A record of significant past illnesses or surgeries.
    • Family Medical History: Information on hereditary health conditions.
  • Lifestyle Information:
    • Smoking Status: To assess risk factors related to smoking.
    • Alcohol Consumption: Insight into alcohol use and potential health impacts.
    • Exercise Frequency: Understanding of the participant’s physical activity level.
    • Dietary Habits: Insights into nutritional practices.
  • Health-Specific Information:
    • Prostate Health Concerns: Any symptoms or concerns related to prostate health.
    • Testicular Health Concerns: Notes on any testicular discomfort or anomalies.
    • Sexual Health: Information on sexual function and health concerns.
    • Mental Health: Understanding of the participant’s psychological well-being.
    • Sleep Patterns: Insight into potential sleep disorders or quality of sleep.
    • Anger Concerns: Notes on temper control issues or related concerns.
  • Consent and Acknowledgment:
    • Consent Checkbox: To agree to the terms of the health check and data use.
    • Signature: Digital signature for verification of information accuracy.

Sign up with WPForms today and access the Men’s Health Check Form Template, which is perfect for health clinics, community centers, and organizations focused on men’s health who want to gather critical health data in a structured manner.