- 123FormBuilder
- Form Templates
- Medical
- Health Assessment Questionnaire
- Ambulance Checklist Form
- Ambulance Transfer Form
- Authorization for Disclosure of Protected Health Information
- Authorization Request Form
- Blood Donation Form
- Body Measurement Form
- Botox Consent Form
- Cancel Appointment Form
- Caregiver Consent Form
- Child Assessment Form
- Child Care Authorization Form
- Child Care Emergency Form
- Child Health Survey
- Child Intake Form
- Chiropractic Intake Form
- Claim Information Form
- Client History Form
- Cosmetic Surgery Survey
- Dental Assessment Form
- Dental Assistant Evaluation Form
- Dental Claim Form
- Dental Clearance Form
- Dental Enrollment Form
- Dental Estimate Form
- Dental Examination Form
- Dental Implant Consent Form
- Dental Insurance Breakdown Form
- Dental Insurance Form
- Dental Insurance Verification Form
- Dental Procedure Medical History Form
- Dental Records Release Form
- Dental Referral Form
- Dental Reimbursement Form
- Dental Screening Form
- Dental Treatment Consent Form
- Dental Treatment Plan Form
- Dentistry Contact Form
- Disability Verification Form
- Doctor Appointment Form
- Doctor Diagnosis Form
- Doctor Referral Form
- Drug Prior Authorization Request Form
- Emergency Contact Form
- Emergency Information Form
- Endodontist Patient Registration Form
- Endodontist Referral Form
- Enrollee Prescription Drug Claim Form
- Facial Intake Form
- First Aid Checklist Form
- First Aid Quiz
- Flu Vaccine Consent Form
- Food Allergy Form
- General Dentist Patient Registration Form
- General Surgery Consent Form
- Health Checklist Form
- Health Evaluation Form
- Health Insurance Claim Form
- Health Insurance Evaluation Survey
- Health Insurance Information Form
- Health Insurance Marketplace Statement
- Health Screening Form
- Health Survey
- Home Delivery Pharmacy Prescription Order Form
- Hospital Admission Form
- Hospital Discharge Form
- Hospital Evaluation Form
- Hospital Patient Satisfaction Survey
- Hospital Registration Form
- Hospital Visitation Form
- Immunization Exemption Form
- Immunization Record Form
- Immunization Record Request Form
- Immunization Waiver Form
- Indemnity Form
- Informed Consent Form
- Laboratory Test Request Form
- Massage Consent Form
- Massage Health History Form
- Massage Therapy Consent Form
- Massage Therapy Intake Form
- Maternity Claim Form
- Medicaid Application Form
- Medicaid Complaint Form
- Medicaid Transportation Form
- Medical Authorization Form
- Medical Card Application Form
- Medical Certificate Form
- Medical Consultation Form
- Medical Declaration Form
- Medical Examination Form
- Medical Examination Report Form
- Medical History Form
- Medical Information Form
- Medical Insurance Form
- Medical Order Form
- Medical Permission Form
- Medical Record Audit Form
- Medical Record Transfer Request
- Medical Records Release Form
- Medical Records Request Form
- Medical Reimbursement Bill Form
- Medical Reimbursement Claim Form
- Medical Release Form
- Medical Summary Form
- Medical Travel Form
- Medical Treatment Authorization Form
- Medicare Application Form
- Medication Administration Record
- Medication Disposal Form
- Medication List Form
- Member Reimbursement Form
- Mental Health Intake Form
- Mental Health Survey
- Newborn Questionnaire
- Nursing Assessment Form
- Nursing Home Application Form
- Nursing Report Form
- Nutrition Consultation Form
- Occupational Therapy Progress Note
- Online Bill Payment
- Online Medical Questionnaire
- Ophthalmology Referral Form
- Oral Surgery Consent Form
- Oral Surgery Patient Registration Form
- Oral Surgery Referral Form
- Organ and Tissue Donation Form
- Organ Donation Form
- Pathology Request Form
- Patient Admission Form
- Patient Appointment Request Form
- Patient Assessment Form
- Patient Demographic Form
- Patient Discharge Form
- Patient Engagement Survey
- Patient Exit Survey
- Patient Health Questionnaire
- Patient History Form
- Patient Intake Form
- Patient Monitoring Form
- Patient Note Entry Form
- Patient Nutrition Assessment Form
- Patient Pain Assessment Form
- Patient Progress Tracking
- Patient Registration Form
- Patient Revocation Request Form
- Patient Satisfaction Survey
- Patient Survey Questionnaire
- Pediatric Consent Form
- Pedodontic Patient Information Form
- Periodontal Referral Form
- Permission To Treat Form
- Personal Representative Request
- Pharmacy Complaint Form
- Pharmacy Registration Form
- Physical Clearance Form
- Physical Exam Form
- Physical Therapy Evaluation Form
- Physician Referral Form
- Physician Satisfaction Survey
- Physician Verification Form
- Police Medical Questionnaire
- Prescription Drug Claim Form
- Prescription Form
- Prescription Refill Request Form
- Proof Of Immunization Form
- Provider Satisfaction Survey
- Psychiatric Evaluation Form
- Psychological Assessment Form
- Psychology Intake Form
- Psychology Referral Form
- Psychotherapy Intake Form
- Referral Request Form
- Request a Routine Medical Appointment
- Request for Access to Protected Health Information
- Request for Accounting
- Request for Confidential Communications
- Request for Diagnosis and Treatment Code Information Form
- Request for Restriction of Use and Disclosure of PHI
- Request Routine Dental Appointment Form
- Request to Amend Protected Health Information
- Request to Inspect a Copy of Clinical Record
- Request to Obtain a Copy of Clinical Record
- Request to Restrict the Use of Confidential Information
- Safety Declaration Form
- School Entry Health Form
- School Medication Form
- School Medication Record
- Self Referral Form
- Social Psychology Survey
- Social Work Intake Form
- Sports Physical Form
- Sports Therapy Consultation Form
- Statement of Disagreement
- Student Health Record Form
- Student Insurance Claim Form
- Test Report Form
- Therapy Consent Form
- Training Requirement Form
- Treatment Consent Form
- Universal Medication Form
- Vaccine Order Form
- Veterinary Prescription Form
- Veterinary Release Form
- Weight Loss Tracking Form
- Wound Assessment Form
Health Assessment Questionnaire Template
- 100 submissions per month
- Digital signatures
- Use your own logo and branding
- Share and publish it anywhere
- Notification emails
Join 1.5 million happy customers that build forms & surveys with 123FormBuilder
Customize template
See howThis questionnaire sample is intended to help you design a series of health questions for patients. Personalize this form according to your choice of fonts and colors and set up multiple recipients and custom autoresponders. Drag and drop advanced fields such as checkboxes and Likert scales. It’s all yours: no coding skills required.
Publish template
See howIt’s easy to publish this form anywhere you want to start a dialogue to raise health awareness. Embed it on your website, post in health education groups on social networks, link from an email. It’s mobile-responsive, so it will look good on computers and smartphones.
Collect & manage data
See howFeel safer knowing the reports of sensitive health issues are housed in a secure database at 123FormBuilder. You can export the results as Excel, CSV, or PDF files or generate easy-to-read charts and graphs that may suggest trends and possible determinants of health.
Optimize your flow
See howUsing an online form to administer your survey on health benefits patients as well as physicians and public health professionals. Answering an online questionnaire can encourage candor as individuals feel more at ease than in a face-to-face interview. With better data, you can provide quality health tips to improve lives.
Other ready to use form templates
Browse through our 1900+ web form templates and select the one that you need.
Request to Amend Protected Health Information
Share this request to amend protected health information with your patients to improve ...
Preview templateMedical History Form
Use this medical history template at your clinic to complete patient records and file u...
Preview templateOrgan and Tissue Donation Form
Share this organ and tissue donation form with people that are interested in donating t...
Preview templateHealth Screening Form
Use our digital template to gather health info about people who join your physical trai...
Preview templateDental Assessment Form
The oral health center you run would greatly benefit from this modifiable dental assess...
Preview templatePhysical Exam Form
This physical exam form template is a great help for health providers. Adapt it to your...
Preview template
