Health Questionnaire Template

The health questionnaire template is a readymade document which lays down the design in which these types of questionnaires are created. It is normally filled by patients or by any interested individual. A health questionnaire helps medical professionals and health institutions in determining the current health conditions of an individual and if they need any further medications or treatments.

Sample Health Questionnaire Template:

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]

Q1. How would you rate your current medical condition?

  • Very healthy and fit
  • Somewhat fit
  • Have mild health issues
  • Have major health issues
  • Suffer from poor health

[The participant needs to check one option, which determines their current health condition]

Q2. When did you get your last health check-up?

  • Date: _________________________________________
  • Doctor’s Name: _________________________________________
  • Clinic: _________________________________________
  • Type of Test: _________________________________________
  • Test Result: _________________________________________

[The Participant needs to provide specific information related to the last medical or health test they had undergone. They can even attach their medical reports or test reports with the questionnaire]

Q3. Which of the following medical conditions do you have?

  • Allergy
  • Diabetes
  • Glaucoma
  • High Blood pressure
  • Low Blood pressure
  • Cholesterol
  • Short sightedness
  • Far sightedness
  • Color blindness
  • Liver ailments
  • Kidney stone
  • Rheumatic fever
  • Bone or joint deformity
  • Asthma
  • Skin disease
  • Others

[The participant can check as many options as are applicable. This will help medical institutions to know about the patients current medical conditions]

Q4. How long have you been suffering from the above medical conditions and what treatments are you taking?

  • 1 ________________ (Year/Months) | Treatment: ________________________
  • 2________________ (Year/Months) | Treatment: ________________________
  • 3________________ (Year/Months) | Treatment: ________________________
  • 4________________ (Year/Months) | Treatment: ________________________
  • 5________________ (Year/Months) | Treatment: ________________________

[The participant needs to put the number of months/years that they are suffering from a particular ailment. Treatment would include medicines prescribed]

Category: Health Questionnaire

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