Advanced Health Assessment Documentation Form
Date:
Patient Demographics and Vital Signs
Patient initials Height
Age Weight
Sex assigned at birth Body mass index (BMI)
Gender identity Temperature
Preferred pronouns Respiratory rate
Race/ethnicity Heart rate
Marital status Blood pressure
Chief Complaint
History of Present Illness (HPI)/Focused Orthopedic
Medications
Name Dose and Directions Indication
Allergies With Reactions
Past Medical History (PMH)
1
, Surgeries and
dates
Other (if
applicable)
Vaccinations
Flu Date: Pneumovax Date: Tetanus Date:
Family History (hx) (specify any disease, if applicable, and if alive or age at
death)
Mother
Father
Siblings
MGM
MGF
PGM
PGF
Personal and Social Hx
Current or former tobacco user: Highest level of education:
Year started: Literacy level and language:
Year stopped: Occupation:
Amount used per day: Financial and insurance concerns:
Alcohol consumption: Support system (family and friends):
Substance abuse: Transportation method:
Exercise habits: Access to phone and internet:
Safety habits (e.g., seatbelt and helmet Religion and related health needs (e.g.,
usage, texting and driving): Jehovah's Witness may decline blood):
Interest and hobbies (health risks):
Sexual history:
2
Date:
Patient Demographics and Vital Signs
Patient initials Height
Age Weight
Sex assigned at birth Body mass index (BMI)
Gender identity Temperature
Preferred pronouns Respiratory rate
Race/ethnicity Heart rate
Marital status Blood pressure
Chief Complaint
History of Present Illness (HPI)/Focused Orthopedic
Medications
Name Dose and Directions Indication
Allergies With Reactions
Past Medical History (PMH)
1
, Surgeries and
dates
Other (if
applicable)
Vaccinations
Flu Date: Pneumovax Date: Tetanus Date:
Family History (hx) (specify any disease, if applicable, and if alive or age at
death)
Mother
Father
Siblings
MGM
MGF
PGM
PGF
Personal and Social Hx
Current or former tobacco user: Highest level of education:
Year started: Literacy level and language:
Year stopped: Occupation:
Amount used per day: Financial and insurance concerns:
Alcohol consumption: Support system (family and friends):
Substance abuse: Transportation method:
Exercise habits: Access to phone and internet:
Safety habits (e.g., seatbelt and helmet Religion and related health needs (e.g.,
usage, texting and driving): Jehovah's Witness may decline blood):
Interest and hobbies (health risks):
Sexual history:
2
