Sample Medical Questionnaire


A sample medical questionnaire is an example of the different medical questionnaires that are designed for the purpose of researching on medical issues. Questionnaires are one of the many methods of data collection in research and a medical questionnaire uses questions to collect data on issues concerning health and medicine in general. A sample medical questionnaire seeks to guide one on how to write medical questionnaires. A sample questionnaire can be written on a variety of topics. Below is an example of a sample medical questionnaire on waterborne diseases.

Sample medical questionnaire on waterborne diseases in the community

Kindly list the waterborne diseases that you know?

____________________________________________

Among the following listed waterborne diseases, rate the waterborne diseases that mostly affect people in your community. 1 representing the disease that most affects your community and 5 representing the one that least affects it.

Typhoid    __________

Cholera __________

Dysentery _________

Amoeba __________

Kindly answer the following questions with ‘yes or no’

Has your community experienced an outbreak of waterborne diseases in the past one year?

___________

Have you ever been treated for waterborne diseases in the past year?

__________

Do you think that your local clinic/hospital is equipped to handle waterborne diseases cases?

_____________

Do you think your neighborhood has…

Good drainage system?

______________

Maintains a high standard of hygiene?

____________

Can you say that waterborne diseases are a major health concern in your neighborhood?

__________________

What measures do you think one should take that can help in the prevention of waterborne diseases?

____________________________________________________________

Category: Medical Questionnaire

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