Medical Questionnaire Form

A medical questionnaire form is a form with questions regarding medical issues and is usually filled by individuals giving details on their medical condition. Medical questionnaire forms can be given to places like hospitals or institutions just before admission. Medical questionnaire forms ask questions whose responses will assist people in gathering information on medical issues. Medical questionnaire forms can be used to determine things like family medical history, an individuals’ medical condition and several other medical issues. Below is an example of a medical questionnaire form used to determine a patient’s medical history.

Medical questionnaire form on a patient’s medical history in a hospital

Personal details

First name                                    middle name                   last name

_______________                        ________________             _________________

Age

_____________

Marital status

Single    _________        Married __________    Other __________

Do you have children?

Yes   ________    No __________

If answer is yes in above, how many children do you have?

______________________

Who is your next of kin?

________________________

Relationship    ________________

Please answer the following questions with a ‘yes or no’ where relevant

Do you have medical insurance?

_____________

Is this your first visit to this hospital?

_____________

Have you ever been admitted in this hospital?

_____________

Have you ever had a major surgery performed on you in the last year?

_____________

Do you have any of the following diseases?

_______ Asthma

_______ Heart diseases

_______ Diabetes

_______ Cancer

_______ Liver complications

Have you fallen sick in the past 6 months?

______________

Can you say that the medical services offered by our hospital are satisfactory?

______________

Category: Medical Questionnaire