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