What Information Is Found on a Patient Assessment Form?


Quick Answer

A patient assessment form usually contains questions about a patient's health, pain level and religious beliefs that impact medical treatment, according to Newton-Wellesley Hospital. It may also include questions about personal habits, such as alcohol consumption. Some forms include a section that determines the patient's risk of dizziness or falling.

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Assessment forms for new patients contain an extensive set of questions about the person's health and medical history. The assessment form for The Myeloma Center at Weill Cornell Medical College asks patients for details about allergies, their history of specific diseases, past surgical procedures and the medical history of family members. The form also contains sections about race, ethnicity, tobacco use and basic socioeconomic factors, such as marital status and occupation. The Myeloma Center's form provides a comprehensive symptom inventory and asks for details about current and past medications.

Some medical providers tailor assessment forms to patient type or the specialty of the facility, as explained by Jupiter Medical Center. A diabetes-focused facility might include questions about the date of diagnosis, the type of diabetes and the patient's level of diabetes education. The form may also cover topics such as the patient's current medication schedule, blood sugar draws and dietary habits. Some forms also assess patients' stress levels and exercise habits.

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