Health Survey Questionnaire


health survey questionnaire is a set of questions that are put together for use in the medical field for medical assessment.

health survey questionnaire focuses on any or all aspects of a person’s medical history in particular a person’s ability to operate.

health survey questionnaire contain questions that relate to a person’s probability of using medications or having ailments that could lead to impairments and a general lack of awareness, concentration and mobility

Once the medical questionnaire has been filled and a person’s fails to meet the required medical standards then the person is said to be ailing.

Sample Health Survey Questionnaire

Below is an example of a health survey questionnaire for an elderly person.

  1. If you were to evaluate your health. What would you say?

__________________________________________________________________

  1. How often do you go for your medical check ups?

__________________________________________________________________

  1. Do you live alone, or with a spouse or relative?

__________________________________________________________________

  1. Are you able to perform everyday activities? If not give reasons why
    _________________________________________________________________
  2. Are you able to walk distances?

__________________________________________________________________

  1. Describe your daily diet.

__________________________________________________________________

  1. Do you feel you have a problem remembering things?

__________________________________________________________________

  1. Are you able to care for yourself?

__________________________________________________________________

  1. Which medications are you currently taking?

__________________________________________________________________

  1. How frequently do you have to take the medication?

__________________________________________________________________

  1. Have all the medicines you take been prescribed by a pharmacist? Name those that are not prescribed.

__________________________________________________________________

  1. Describe a typical day for you.

__________________________________________________________________

  1. How old are you?

__________________________________________________________________

  1. Gender
    • Male
    • Female

Category: Survey Questionnaire

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