Health Appraisal Questionnaire


A health appraisal questionnaire is compiled by a medical institution or entity to assess the medical health of a certain individual. The questionnaires help the entities to keep record of the mental, physical and emotional needs of the respective individual. It helps in keeping track of how the individual’s daily habits, life style and medical history affect his/ her health and how can his/ her health be improved/ appraised. The questionnaire contains simple and straight forward questions which can be answered by anyone very easily.

Sample Health Appraisal Questionnaire

Name:

Age:

Gender:

Blood group:

Date of Birth:

Contact No.:

Mobile No.:

Correspondence Address:

Kindly answer the following questions to the best of your knowledge:

1. How often do you consume the following dairy products:

a. Milk products

b. Margarine

c. Butter

d. Cheese

2. Do you often consume fried food items? Give specifications like the type of fried food, the amounts and the frequency etc.

_____________________________________________________________________

3. Do you consume fast food/ junk food on regular basis? If yes then specify amounts, frequency, type etc.

_____________________________________________________________________

4. Do you consume sweets, candies or any artificial sweeteners? Give specifications.

_____________________________________________________________________

5. Do you smoke? If yes, then specify what, amounts etc.

_____________________________________________________________________

6. Do you consume alcohol or any alcoholic beverages? If yes then specify what, amounts etc.

_____________________________________________________________________

7. Have you tried dieting? Do you do it often?

_____________________________________________________________________

8. Do you ever work out/ exercise? How often and the type?

_____________________________________________________________________

9. What time do you sleep and wake up? Mention hours of sleep you have.

_____________________________________________________________________

10. What type of work do you do? Also mention the working hours and conditions.

_____________________________________________________________________

11. List any and every medication (if any) that you are currently taking.

_____________________________________________________________________

12. Tick if you have any of the following problems. Give specifications.

a. Blood pressure _______________

b. Cholesterol __________________

c. Joint pains ___________________

d. Body aches __________________

e. Sweat problems ______________

f. Depression __________________

g. Allergies ____________________

Deficiencies _________________

 

Category: Health Questionnaire

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