Medical Questionnaire Questions

Medical questionnaire questions are created in such a way that they throw light on a patient/participants current medical condition and medical history. This type of medical questionnaire provides an insight into various patient conditions and this information can be referred to by medical institutions when a patient in admitted or during routine physician’s check up.

Sample Medical Questionnaire Example:

Name of the patient: ____________________________

Address: ________________________________________

Age: ___________

Gender: ________________

Email: ______________________

Physicians Name:__________________________________

Last date of checkup: _______________________________

Q1. What type of medical checkup did you undergo recently? Please mention the details.

• Type:_____________________
• Medication:_____________________
• Date of check up:_________________
• Physicians Name:_________________
• Medical Institution:________________

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

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

Q3. How often do you visit your physician for a routine check up?

• Once a month
• Once a quarter
• Once in 6 months
• Once in a year
• Don’t know

Q4. Are currently on any specific medication? If yes then please specify name of the medication and what it is for

• Yes
• No
• Medication: ____________________________
• Medical Condition:____________________________

Q5. Do you own a medical insurance policy? If yes, please mention policy number and what it covers?

• Yes
• No
• Insurance Policy Number:
• Cover:

Q6. Do you suffer from a disorder or medical condition in the following areas?

• Blood Sugar
• Cholesterol
• Liver
• Kidney
• Heart/lungs
• Abdomen
• ENT (Ear,Nose,Tongue)

Q7. Have you undergone any surgery in the near past? If yes, then please mention type of surgery and post surgery treatment.

• Yes
• No
• Type of Surgery:_______________________
• Treatment:____________________________