Employee Medical Questionnaire

Employee medical questionnaires are questionnaires given to employees for the purpose of finding out their medical conditions. Employee medical questionnaires are normally completed by prospective employees before being employed or at any other time that the employer might require that information. The employee medical questionnaire asks personal questions about the individual’s condition. The main purpose of designing a medical questionnaire is to find out whether the employee is medically fit to carry out the responsibilities and duties that the job entails. Below is an example of a medical questionnaire.

Personal details

First name                                       Middle name                        Last name

___________________                  ____________________          _________________

Age ______________

Marital status (please tick one)

Single __________   Married _________    Other ________

Do you have any children?

Yes _______   No ________

If answer is ‘yes’ in above state the number of children you have.


Position in the organization ________________

Kindly, answer the following questions with ‘yes or no’

Are you physically disabled?


Do you use hearing aids or contact lenses/glasses?


Do you have health insurance?


Have you fallen sick in the past six months?


Do you have any illness that requires you to be constantly on medication?


Have you ever been addicted to drugs or alcohol?


Have you had a major surgery in the last one year?


Does your family have a history of any of the following diseases?

Asthma _______

Heart disease _______

Cancer __________

Would you be willing to undergo an independent medical examination by the company’s doctor?


Category: Medical Questionnaire

Comments are closed.

Copy Protected by Chetan's WP-Copyprotect.