Health screening form 2025

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4.5 out of 5

51 votes

The document is a confidential health screening form intended for patients to provide their health information to a healthcare provider. It includes sections for patient and provider details, health screening information with recommended reference ranges for various health metrics, and instructions for participants on how to complete the screening either at a worksite event or through their healthcare provider. The form emphasizes confidentiality and outlines the responsibilities regarding potential costs associated with the screenings.

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Click ‘Get Form’ to open the health screening form in the editor.
Begin by entering your Patient Information. Fill in your legal name, last four digits of your SSN, home and work telephone numbers, and date of birth.
In the Health Screening Information section, indicate the Date of Service and whether you have a fasting specimen by selecting 'Yes' or 'No'.
If applicable, enter your results for Total Cholesterol, HDL Cholesterol, LDL Cholesterol, Triglycerides, Blood Glucose, Systolic Pressure, Diastolic Pressure, and Body Mass Index (BMI). If you don’t know your BMI, provide your height and weight.
Complete the Health Care Provider Information by entering the provider's name, license number, phone number, and ensure they sign and date the form.
Once all fields are filled out accurately, review your information for completeness before submitting.

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See more health screening form versions

We've got more versions of the health screening form form. Select the right health screening form version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2023	4.1 Satisfied (45 Votes)
2023	4.3 Satisfied (27 Votes)
2023	4.1 Satisfied (45 Votes)
2022	4.8 Satisfied (52 Votes)
2021	4.2 Satisfied (40 Votes)
2021	4.8 Satisfied (61 Votes)
2021	4.7 Satisfied (124 Votes)
2021	4.8 Satisfied (145 Votes)
2021	4.8 Satisfied (89 Votes)
2021	4.8 Satisfied (49 Votes)
2021	4.5 Satisfied (36 Votes)
2021	4.8 Satisfied (31 Votes)
2020	4.8 Satisfied (51 Votes)
2020	4.5 Satisfied (50 Votes)
2020	4.8 Satisfied (39 Votes)

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What is the main purpose of the health screening form?

A health screening form is purposely great in identifying potential health risks and ensuring adequate care is administered. It is also useful because it provides information to create solutions or controls that keep the environment safe.

What is a health screening form?

A health screening form is a document used to collect information about an individuals health status, potential symptoms, exposure to illnesses, and other relevant health-related details. Health screening forms are an important tool for promoting early detection and prevention of disease.

What is an example of a health screening?

Annual Physical Examination Blood tests to check blood sugar and cholesterol levels. Immunizations, such as the flu shot. Pelvic exam (women) Weight, blood pressure, and temperature check. Screening questions about depression, smoking, and alcohol use.