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: ____________________________

Address: ________________________________________

Age: ___________

Gender: ________________

Email: ______________________

Physicians Name:__________________________________

Q1. Have you recently undergone any medical checkup? If yes then please provide the date and type of examination or checkup.

  • Yes
  • No
  • Date:_____________________
  • Type:_____________________

Q2. Do you suffer from any specific allergies? If yes then please provide the type of allergy and medication

  • Yes
  • No
  • Type:_____________________
  • Medicine:_____________________

Q3. Which of the following vaccinations have you taken so far?

  • Varicella
  • Influenza vaccination
  • Quadrivalent vaccine
  • Meningococcal vaccination
  • Tetanus, diphtheria, pertussis
  • Human papillomavirus
  • Measles, mumps, rubella (MMR)
  • Herpes Zoster
  • Pneumococcal
  • 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.

  • Yes
  • No
  • 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
  • Medication:______________________________
  • Diabetes Type 1: Yes/No
  • Medication:______________________________
  • Diabetes Type 2: Yes/No
  • Medication:______________________________

Category: Medical Questionnaire

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