Health Questionnaire Questions


Health questionnaire questions are medically relevant and focused at deriving maximum information from a participant with respect to their current and past medical conditions and health issues. A health questionnaire is used by medical institutions and health experts during patient treatments.

Sample Health Questionnaire Questions:

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?

  • Last week
  • Fortnight back
  • A few weeks back
  • Last month
  • A few months back

Q2. Are you allergic to any of the following?

  • Pollens
  • Animal Hair
  • Insect bite
  • Dust mite
  • Sesame seeds
  • Mold
  • Latex
  • Perfume
  • Medicines
  • Eggs
  • Nuts
  • Others

Q3. Do you suffer from any of the following skin problems?

  • Acne
  • Eczema
  • Seborrheic dermatitis
  • Skin cancer
  • Psoriasis
  • Impetigo
  • Scabies
  • Necrotizing fasciitis
  • Ringworm
  • Athlete’s foot

Q4. What were the results for the following tests conducted previously?

  • Blood Pressure: ___________________________
  • Systolic (mm Hg) : ___________________________
  • Diastolic (mm Hg) : ___________________________
  • Blood Sugar: ___________________________
  • Fasting blood sugar level (FBS) : ___________________________
  • Random blood sugar level(RBS) : ___________________________
  • 2-hour postprandial blood sugar level: ___________________________

Q5. Are you currently on any type of medication? If yes, then please mention the disorder and the name of medicine/drug.

  • Yes
  • No
  • Disorder:____________
  • Medicine:____________

Q6. Do you have cholesterol? If yes then please provide the following levels

  • Yes
  • No
  • LDL cholesterol:__________________
  • HDL Cholesterol:__________________
  • Triglycerides:__________________

Category: Health Questionnaire

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