A general health survey questionnaire is aimed at evaluating the general health of the individuals participating in the survey. This survey questionnaire is used in preparing various kind of market research or other medical based research reports which help in assessing the general health pattern of people. Given below is a sample of general health survey questionnaire:

Sample General Health Survey Questionnaire

Name of the Participant :                   _________________________________________

Full Address of the Participant :      __________________________________________

Occupation of the Participant :         __________________________________________

Date of Birth of the Participant :        __________________________________________

Email Address of the Participant :     __________________________________________

Contact Number of the Participant : __________________________________________

Kindly answer all the questions and share the correct information (The information provided here will be kept confidential always and not shared with anyone):-

Q1. How frequently do you consume alcohol? Please specify the frequency provided below as applicable?

a) Daily

b) Weekly

c) Monthly

d) Occasionally

Q2. How would you rate your overall health?

a) Good

b) Average

c) Poor

Q3. Are you suffering from any specific disease or illness, please describe the signs and symptoms experienced by you on account of it?


Q4. Is there a family history of any of the following diseases?

a) Diabetes

b) High blood pressure

c) Stroke

d) Heart Diseases

Q5. Have you undergone any surgery or serious treatment in past one year? If yes, then please provide details?


Q6. Please specify the activities that you indulge in order to maintain good levels of fitness and overall health?

a) Brisk walking

b) Cycling

c) Aerobics

d) Others Pl specify____________

e) None

Q7. How often do you fall ill during a year? Please specify the number of times you have not been able to carry on routine work such as going to office etc on account of your illness?