Health Questionnaire Format

A health questionnaire format needs to be created in such a way that it enables the respondent or participant to provide the information that is required by health institutions, researches, and health professionals. Health questionnaires are useful for different health and medical care organizations as they can use the health information of a patient during specific treatments.

Sample Health Questionnaire Format:

Name: ____________________________ [Name of the participant]

Address:__________________________ [Home Address of the participant]

Phone: _____________________ [Phone of the participant]

Gender: _____________________ [Gender of the participant (M/F)]

Age:______________________________ [Age of the participant]

Email: __________________________________ [Email address of the participant]

Name of the family Doctor: __________________________________ [Family Doctor of the participant]

Doctor’s phone: __________________________________ [Phone number of family doctor]

First Question: [The First question should be aimed at getting the basic medical or information from the participant or patient. Questions should revolve around height, weight, skin problems, eye sight, hearing, birth mark, blood group etc]

Second Question: [The second question should focus on deriving information related to specific activity. Health and fitness activities that a patient/participant is indulged in will provide an insight into the fitness condition of an individual.]

Third Question: [The third category of questions should be focused on different categories like vaccination, skin diseases, blood pressure condition, heart condition, abdominal conditions, ENT, and medical conditions of various organs in the body. Questions like: Do you have any type of skin allergy or are you allergic to any food would be appropriate.]

Fourth Question: [The fourth and final category of questions should revolve around the participant/patient’s current medical care. In this category, questions related to previous medical or laboratory tests and results, diseases and treatments etc should be put up. Questions like when did you get your last pregnancy test done or when did you undergo a blood test are appropriate]

Category: Health Questionnaire

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