Telehealth Patient Health Risk Assessment Form
Patient Information
Full Name
Date of Birth
Phone Number
Email
Address
Insurance Provider
Medical History
Pre-existing Conditions
Current Medications
Allergies
Lifestyle & Risk Factors
Do you smoke?
No
Yes
Former Smoker
Do you consume alcohol?
No
Occasionally
Regularly
Physical Activity Level
Sedentary
Light
Moderate
Active
Height
Weight
Relevant Family Medical History
Symptoms & Concerns
Current Symptoms or Health Concerns
Reason for Telehealth Visit