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

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