Health Self Assessment Questionnaire


A health self assessment questionnaire is taken by an individual seeking to obtain medical assistance. The questionnaire helps the individual in identification of health issues if any along with providing insights into the lifestyle being lead by the individual.

On the basis of the questionnaire the health condition of the individual is assessed and medical assistance is provided accordingly.

Sample Health Self Assessment Questionnaire

Name of the assessee:-

Complete address:-

Contact number:-

Email address:-

Present working status:-

1. Do you suffer with any kind of disease or have any form of disability?

a) Yes

b) No

2. Are you able to take care of your personal needs all by yourself without the assistance of another person on a daily basis?

a) Yes

b) No Pl specify details ____________

3. Do you need help to cook and eat your everyday meals?

a) Yes

b) No

4. Have you ever been alone at home and had a medical emergency with no body at help?

a) Yes

b) No

5. Are you able to travel independently out of the home without any assistance?

a) Yes

b) No

6. Do you suffer with any memory loss that disables you from interacting with others at home and outside?

a) Yes

b) No

7. If you are an employed person are you able to maintain a good work life balance easily?

a) Yes

b) No

c) Not applicable

8. Do you manage your finances well so that there is some amount left for medical needs?

a) Yes

b) No

9. What is your idea of a person’s wellbeing?

_________________________

10. What does leading a fit and active healthy life mean according to your understanding and personal experience?

_________________________

11. On a scale of 0-5 wherein 0 is least and 5 is best how do you rate your overall health condition?

___________________

Category: Health Questionnaire

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