Health Questionnaire Example


A health questionnaire example is a sample questionnaire, which is created specifically to derive health related information from an individual. The primary objective is to know the current medical condition of the participant and the health questionnaire should also provide an insight into an individual’s medical history.

Sample Health Questionnaire Example:

Name of the participant: ____________________________

Address:__________________________

Phone: _____________________

Gender: _____________________

Age:______________________________

Email: __________________________________

Name of the family Doctor: __________________________________

Doctor’s phone: __________________________________

Q1. When did you last visit a doctor or physician?

  • Date: __________ (mm/dd/yy)
  • Doctor’s Name/Clinic: _________________

Q2. What are the results from your last test on the following?

  • Height (in/cm)    : _________________
  • Weight (lb/Kg): _________________
  • Eyesight: _________________
  • Intraocular tension (Age 40+): _________________
  • Right(mm.Hg):: _________________
  • Left(mm.Hg): _________________
  • Pulse (sitting)      : _________________
  • Blood Pressure: _________________

Q3. Has any abnormality been recorded in any of the following areas? If yes, then please specify the type of abnormality in the given space.

  • Head: __________________________________
  • Throat: __________________________________
  • Nose : __________________________________
  • Eyes : __________________________________
  • Heart: __________________________________
  • Breast: __________________________________
  • Lungs: __________________________________
  • Abdomen: __________________________________
  • Vascular System: __________________________________
  • Anus and Rectum: __________________________________
  • Spine – Musculoskeletal: __________________________________
  • Endocrine System: __________________________________
  • Neurologic: __________________________________
  • Pelvic: __________________________________
  • Psychiatric: __________________________________

Q4. Which of the following clinical tests have been conducted on you in the recent past? Please mention the result of the test as well.

  • Stool Examination: __________________________________
  • Chest X-ray: __________________________________
  • ECG: __________________________________
  • Tuberculin test – PPD: __________________________________
  • Urinalysis: __________________________________
  • Mammography: __________________________________
  • Blood Glucose: __________________________________
  • SGOT: __________________________________
  • SGPT: __________________________________
  • Cholesterol: __________________________________
  • Uric Acid: __________________________________

Q5. Do you have any allergies? If yes then please mention the type of allergy and medication taken.

  • Yes
  • No
  • Allergy type: ___________________________
  • Medication:_____________________________

Category: Health Questionnaire

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