Health Care Assessment Questionnaire


A health care assessment questionnaire is one that is obtained from a health care organization for the purpose of obtaining health insurance. This questionnaire helps to assess the health condition of the individual and the high levels of risk that the person is exposed to.

On the basis of the questionnaire the health care organization provides a recommendation with regard to the health insurance that the individual is eligible for.

Sample Health Care Assessment Questionnaire

Name of the individual ——————————————

Address of the individual ——————————————

Contact number of the individual ——————————————

Blood group ——————————————

Gender —————————————–

1. What is the importance of health for you?

___________________________________

2. How many times do you eat fried and junk food in a week?

a) Everyday

b) Weekly twice

c) Weekly thrice

d) Never

3. How many times do you eat sweets and sugared products?

a) Everyday

b) Weekly twice

c) Weekly thrice

d) Never

4. How many times do you consume alcohol or smoke according to the parameters given below?

a) Everyday

b) Weekly twice

c) Weekly thrice

d) Never

5. Do you follow a diet plan that is filled with fruits, vegetables and nutritious food every day?

a) Yes

b) No

6. Do you suffer from cholesterol or heart problems?

a) Yes

b) No

7. Do you indulge in activities that keep you healthy in active?

a) Yes ( If Yes, which type of activities)

b) No

8. Do you work in such a job role that leaves you with a sedentary life?

a) Yes

b) No

9. Please specify if you have experienced any of the following symptoms in the recent times?

a) Sweating

b) Panting when active

c) Fainting episodes

d) Allergies

10. Do you have an ideal body mass index where in your weight is optimum to your height?

a) Yes

b) No

Category: Health Questionnaire

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