Health Risk Appraisal Form

Health Risk Appraisal Form — Form Fields

This healthcare template includes 7 fields. Identify individual health risks through lifestyle, family history, and biometric self-reporting. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Age (number, required)
• Do you currently smoke or use tobacco? (multiple choice, required) — options: Yes, No, Former smoker
• How many days per week do you engage in moderate physical activity? (dropdown selection, required) — options: 0 days, 1–2 days, 3–4 days, 5+ days
• Do you have a family history of any of the following? (select all that apply) (checkboxes, optional) — options: Heart disease, Stroke, Cancer, Diabetes, None
• How would you rate your overall stress level? (1 = low, 5 = very high) (rating, required)
• Have you had a physical exam or health screening in the past 12 months? (multiple choice, required) — options: Yes, No