Physical Health Questionnaire

A physical health questionnaire aims to identify the health and fitness of individuals taking the questionnaire. This questionnaire is mainly made use of by health care specialists to identify the ailments that the individuals are suffering from and precautions that need to be taken before providing medical advice.

The primary aim of this questionnaire is to assess the health condition of the individuals and promote better health and fitness through awareness about the same.

Sample Physical Health Questionnaire

Name of the individual —————————–

Address of the individual—————————

Contact no of the individual————————

Sex of the individual———————————

Age of the individual——————————–

1. Can you provide the things that you do from the following to keep yourself healthy?

a) Eat five servings of fruits and vegetables everyday

b) Walk or jog for at least 30 minutes everyday

c) Avoid junk, fatty food and alcohol consumption as much as possible.

d) Keep a positive attitude towards life

e) All of the above

2. Is there a history of any of the ailments that you parents have suffered during their life time? Please tick all that are applicable.

a) Heart disease – Pl tick if applicable ___________

b) High cholesterol levels– Pl tick if applicable ___________

c) High blood pressure– Pl tick if applicable ___________

d) Diabetes– Pl tick if applicable ___________

e) Lung diseases– Pl tick if applicable ___________

3. If you are a woman and in the reproductive age do you take any birth control pills?

a) Yes

b) No

c) Not applicable

4. Do you feel any of the following symptoms when walking, running or climbing stairs?

a) Breathlessness– Pl tick if applicable ___________

b) Severe pain in calf muscles and knees– Pl tick if applicable ___________

c) Profuse sweating– Pl tick if applicable ___________

d) Pain in the chest– Pl tick if applicable ___________

5. Do you eat a regular meal every day?

a) Yes

b) No

Category: Health Questionnaire

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