Medical Examination Questionnaire

A medical examination questionnaire is to be filled by a person who has come into a hospital for the treatment of some disease or illness. Such a questionnaire is usually given by the doctor to his/her patients so that they can examine the health of the patient before starting the treatment. In a medical examination questionnaire a doctor gets the medical information about of the patient which would be helpful in curing the illness of the patient.

This questionnaire includes multiple choice questions, as well as subjective questions in which the person may be required to elaborate his or her answer. Given below is a sample of such a medical examination questionnaire.

Sample Medical Examination Questionnaire:

Today’s date:

Name of the patient:

Gender:   M/F




Date of birth:

Residential address:

Residence phone no. :

Email id:

Q1. Are you allergic to any medicines? If yes then give their names.

  • No
  • Yes, _______________
  • ________________
  • ________________

Q2. When was the last time you had your medical checkup?

_________________________ (mention the date)

Q3. Have you got your blood tested recently?

  • Yes
  • No

Q4. Have you tested your blood pressure recently?

  • Yes
  • No

Q5. Do you have diabetes?

  • Yes
  • No
  • Don’t know

Q6. Do you include exercise in your daily routine?

  • Yes
  • No
  • Sometimes
  • Rarely

Q7. Do you have any contagious disease such as contagious hepatitis and contagious tuberculosis?

  • Yes
  • No
  • Don’t know

Q8. Have you ever developed any of the following medical condition?

  • Loss of hearing
  • Loss of sight
  • Skin condition
  • Backache
  • Blood related disease
  • Any other (please specify) _________________

Q9. Do you indulge in activities such as drinking or smoking?

  • Only drinking and not smoking
  • Only smoking and not drinking
  • Both of them
  • None

Category: Medical Questionnaire

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