Health Questionnaire Form

The health questionnaire form is mainly used by insurance companies who issue medical cover to gauge the well-being and hence the eligibility of a private or individual medical cover. The standard form used in the insurance industry current has a scoring system that requires people to score 325 or more points to avoid rejection.  Usually, this form is designed to create the impression that the researcher expects one to be normal or healthy. Depending on the diagnosed illnesses, treated, or ones that a person is taking medication for, the person obtains a score that is used to gauge his or her eligibility.

Below is a sample:

Full Name: ____________________________________________________

Date of Birth: __________________________________________________

Contact Details: ________________________________________________

Height: ________________________ Weight__________________

Male?Gender:             Female????????????????????????

Tick the box besides the disease that you have been diagnosed with, treated or currently being monitored for


Lou Gehrig’s disease________


Limb amputation___________

Biliary Atresia_____________

Cerebral Palsy_____________

Liver Cirrhosis____________

Brain or spinal chord malformation (central nervous system)_________

Cystic Fibrosis______________



Fragile X Syndrome_________

Huntington’s chorea_________


Irritable Bowel Syndrome_______


Q1. Have you ever been diagnosed and treated for:

Cancer __________

Heat ailments

Hepatitis C___________

Q2. Have you suffered digestive ailments in the past two years?

If so, specify_______________________

Q3. Do you suffer from any chronic disease? _______

If so, specify_______________

Q4. Have you approached other health insurance cover providers for the same service?

If so, was your request for cover rejected? _____________

Q5. Do you have any existing addictions to drugs or alcohol?

Category: Health Questionnaire

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