The Health Screening Form Template UK is offered in multiple formats, including PDF, Word, and Google Docs, featuring customizable and printable versions for your convenience.
Health Screening Form Template UK Editable – PrintableSample
Health Screening Form Template UK 1. Personal Information 2. Contact Information 3. Emergency Contact Details 4. Medical History 5. Current Medications 6. Lifestyle Information 7. Reason for Screening 8. Consent and Confidentiality 9. Signature and Declaration
PDF
WORD
Examples
[Full Name]
[Date of Birth]
[Address]
[Phone Number]
[Email Address]
[Emergency Contact Name]
[Emergency Contact Phone Number]
[Relationship]
Please list any existing medical conditions: [Conditions].
Have you had any surgeries? [Yes/No, if yes, please specify].
Please list any allergies to medications, food, or environmental factors: [Allergy Details].
Please list any medications you are currently taking: [Medications].
Do you smoke? [Yes/No].
Do you consume alcohol? [Yes/No, if yes, please specify amount].
Do you exercise regularly? [Yes/No, if yes, please specify type and frequency].
I consent to the collection and processing of my personal health information for the purposes of this health screening.
[Signature of the Patient]
[Date]
[Patient Name]
[Date of Birth]
[Address]
[Phone]
[Email]
[Contact Name]
[Contact Phone]
[Relationship to Patient]
Do you have any ongoing health issues? [List issues].
Have you had any hospital admissions in the past year? [Yes/No, if yes, provide details].
List any known allergies: [Details].
Have you ever had an allergic reaction requiring medical attention? [Yes/No].
List all medications you are currently prescribed or taking: [List medications and dosages].
Do you smoke? [Yes/No].
Do you drink alcohol? [Yes/No, if yes, specify amount].
Do you engage in physical activity? [Yes/No, specify type and frequency].
I authorize the collection of my medical information for health screening purposes.
[Signature]
[Date]
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