Health Screening Questionnaire


A health screening questionnaire is a survey tool often used for vetting people on the basis of their health. Often this happens with employers who need to recruit employees who meet a specific health criterion. Respondents are asked to respond with all honesty to allow the employer either make decisions about recruiting them, or put in place the adaptation mechanisms required upon recruitment.  Applicants are assured that medical examinations won’t be carried in addition to the survey, unless their stated conditions raise the need for additional assessment by a general practitioner. Some of the general questions that appear in this form of questionnaires include immunization history, and blood tests.

Sample Health Screening Questionnaire

Name_______________________

Age________________________

Address _________________________

Telephone Number_____________________

Q1. Please provide us with an occupation history stating the nature of work and the location you have held in the last five years.

Job title Start date Stop date Employee Location

Q2. Immunization history

Please use YES, NO or DON’T KNOW responses for the following immunizations

a.BCG (Tuberculosis) _________

b.Polio _________

c. German measles (Rubella) _________

d.Hepatitis B _________

e.Diphtheria _________

(If you have any vaccination records, please attach copies of the same on this survey form)

Q3.Have you had recent blood tests to check your level of immunity against

a.Rubella

b.Hepatitis B

Q4. State any health problems you may have experienced in the last one year

____________________________
____________________________

Q4. List any medication or treatment you are currently using under a doctor’s recommendation

Q5. Do you have a disability which has hampered your work in the past?

If so, describe the nature of work you were doing at that time

____________________________
____________________________

Category: Health Questionnaire

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