Medical Questionnaire Example
A medical questionnaire example is a sample questionnaire, which is created specifically to get medical information of a patient/participant. The information can be related to various anatomical areas or areas of medicine like abdominal, blood, cardio etc. The objective is to determine the current medical condition of the patient/participant.
Sample Medical Questionnaire Example:
Name of the patient: ____________________________
Q1. Have you recently undergone any medical checkup? If yes then please provide the date and type of examination or checkup.
Q2. Do you suffer from any specific allergies? If yes then please provide the type of allergy and medication
Q3. Which of the following vaccinations have you taken so far?
- Influenza vaccination
- Quadrivalent vaccine
- Meningococcal vaccination
- Tetanus, diphtheria, pertussis
- Human papillomavirus
- Measles, mumps, rubella (MMR)
- Herpes Zoster
- Hepatitis A
- Hepatitis B
- All of the above
Q4. Do you suffer from any skin disorders or ailments? If yes, then please mention the type.
Q5. Please answer the following questions.
- What is your current white blood count?:____________________________
- What do your current red blood count?:_________________________
- What is your LDL?:________________________
- What is your HDL?:_____________________________
- What is your Trigycerides?:______________________________
- What is your height?:________________________
- What is your weight?:________________________
Q6. Do you suffer from any of the following? If yes then please mention the medication currently prescribed.
- Diabetic Hypoglycemia: Yes/No
- Diabetes Type 1: Yes/No
- Diabetes Type 2: Yes/No
Category: Medical Questionnaire