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__________________
Tick the box besides the disease that you have been diagnosed with, treated or currently being monitored for
Lou Gehrig’s disease________
Brain or spinal chord malformation (central nervous system)_________
Fragile X Syndrome_________
Irritable Bowel Syndrome_______
Q1. Have you ever been diagnosed and treated for:
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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