Health Assessment

Complete this form to help us understand your current health status and care needs.

SECTION 1: CURRENT HEALTH PROFILE - A. Diagnoses

Check all that apply:

Other:

Which condition affects your daily life the most?

Any new diagnoses or major health changes in the last 6 months?

No Yes →

Do you have any allergies?

No known allergies Yes

List your allergies (enter N/A if none):

Allergy #1 - Type:

Allergy #2 - Type:

Allergy #3 - Type:

Additional allergies (if more than 3):

What happens during a reaction?

How severe are your reactions?

Mild (rash, itching) Moderate (swelling, hives) Severe (anaphylaxis)

Do you carry an EpiPen or epinephrine auto-injector?

Yes No N/A

Complete this section to help us keep you safe from allergic reactions.

What precautions prevent allergic reactions?

What items must be avoided?

If an allergic reaction occurs, what are the immediate steps?

When should 911 be called?

Primary Emergency Contact for Reactions:

Doctor to notify:

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