Medical Questionnaire Format

A medical questionnaire is used by medical institutions in order to get necessary and relevant information from the patients, and other people who are receiving health care. In order to frame such effective questionnaire, medical questionnaire format proves to be very helpful.

Sample Medical Questionnaire Format:

Name: ____________________________ [Name of the patient]

Address:__________________________ [Home Address of the patient]

Phone: _____________________ [Phone of the patient]

Gender: _____________________ [Gender of the patient (M/F)]

Age:______________________________ [Age of the patient]

Email: __________________________________ [Email address of the patient]

Physician’s Name: __________________________________ [Name of the family physician]

First Question: [The First question needs to be aimed at deriving basic medical information of the patient or participant. Information pertaining to last medical checkup, dental checkups etc can be derived by using the right questions. Questions can be framed as: When was the last time you had a medical checkup? What type of medical checkups have you had? ]

Second Question: [The second question should focus on deriving secondary medical information or those pertaining to the basic types of checkups. Questions can be data driven where patients/participants can provide medical values like their current blood pressure, height, weight etc. Questions can be like: When did you last get your blood pressure checked? What is your current blood pressure? Do you suffer from high or low blood pressure? Are you taking any medication for the same?]

Third Question: [The third category of questions can be multiple choices in nature and should be targeted at various medical conditions that the participant or patient might be suffering from. Appropriate questions in this category will include: do you have any allergies? Do you suffer from any blood disorders? Do you suffer from any skin disorders? ]

Fourth Question: [The fourth and final category of questions should address medical history of the patient/participant and can include information on vaccinations and current or past medications. Questions can be framed as yes-no questions or even multiple choice options.]

Category: Medical Questionnaire

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