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Health Assessment

A short health summary the State of Utah requires — allergies and food sensitivities, chronic conditions, current medications, and any special daily care instructions.

Fill out the State of Utah Health Assessment online. If you'd rather not list anything for a section, just type "None".

View the official PDFDownload a blank copy

Preview of the official form

This is the exact State of Utah form. Filling it out on this page sends Sara the same information.

Signature

By submitting, I acknowledge:

  • I attest that the information I have provided in this form is accurate and up-to-date.
  • I understand that a separate medication permission form must be completed for any medication left with the provider.

Your information is sent securely to Sara. We never share it.