Health and social questionnaires are used to understand the social well being of households in a particular region, area, or city. The questionnaires can contain information varying from general health condition to specific medical conditions, work related illness, child health, pregnancy and breastfeeding, education, employment, and physical measurements among others. This type of questionnaire is filled by every member of a household.

Health And Social Questionnaire Sample

Name of the individual: _______________________________________

Sex: _______  Age: _________  Marital Status: ____________________

Role in the Household: ________________________________________

Relationship with head of household: _____________________________

Occupation: ____________________ College/School: _______________

Type of accommodation: (Rented/Rent free/Owned): ________________

Address: ___________________________________________________

City: ________________ State: ______________  Zip: ______________

Telephone: ____________________  Fax: ________________________

Q1. How would you score your general health?

a)   Excellent

b)   Very Good

c)   Good

d)   Average

e)   Bad

f)    Poor

Q2. In the last 12 months how often have you visited a doctor for treatment of medical ailment?

a)   Once

b)   1-5 times

c)   5-10 times

d)   More than 10 times

Q3. Do you have any long standing disability or illness? If yes, please specify

a)   Yes

b)   No

c)   Illness/Disability:_____________________________

Q4. Have you faced any pregnancy complications?

a)   Yes

b)   No

Q5. Which of these do you follow or use on a regular basis?

a)   Healthy diet

b)   Exercise

c)   Aerobics

d)   Herbal medicine

e)   Adventure sports

Q6. Do you have any of the following habits?

a)   Smoking

b)   Drinking Alcohol

c)   Caffeine

d)   Sleeping medicines

Q7. Please provide information on the following:

Height:_________  Weight: _________

Waist: __________ Chest: __________

Q8. Are you religious?

a)   Yes

b)   No

Q9. How often do you visit a place of worship?

a)   Every day

b)   Once a week

c)   Only on weekends

d)   Once in a fortnight

e)   Once in a month

f)    Never

Q10. What is your income per month or annually?