Medical Evaluation Form


A medical evaluation form is a document which contains an assessment of a patient’s medical history and current medical condition. This is a prerequisite in any medical institution or hospital before more specialized checks. Individuals are expected to undergo general medical evaluations after repeated intervals to ensure the detection of diseases and for general healthcare and safety. Hence, a medical evaluation form must be well thought out and particularized according to necessity.

Sample Medical Evaluation Form:

Medical Evaluation Form

Name: ___________________ Age: _______________ Date of birth: __________________

Address: _________________ Contact Number: __________________ Purpose of medical evaluation: _______________________

Personal information: [Please fill in the requisite information]

Height: _______________

Weight: _______________

Pulse rate: _______________

Blood pressure: ___________________

Heart rate: ________________

Medical History of Patient:

Any history of prior illness: ________________________________________

Family history of cancer, diabetes, asthma, chronic arthritis: ____________________________

Please answer the following questions carefully, supplementing with medical records wherever needed:

1. Are you in the habit of smoking or chewing tobacco?

________________________________________

2. Have you been on long term medication in the past? If yes, mention the name of medicines prescribed and ailment for which they had been prescribed.

__________________________________________

3. How often do you undergo a medical checkup? When was the last time you underwent a medical checkup? [attach report]

_________________________________________________

4. Have you had a drug history? Have you ever abused prescriptive drugs?

__________________________________________________

5. Are you allergic to any substance?

___________________________________________________

6. Do you feel weakness and nausea frequently? When was the last time you had been hospitalized and for what?

____________________________________________________

7. Please mention the name of your consulting doctor: ____________________________

Category: Medical Evaluation

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