Health assessment questionnaire is a document that is used to assess the overall health of an individual. These types of questionnaires can be used by various organizations, companies, medical centers, hospitals and other such places. Health assessment is the assessment of an individual’s complete health, i.e. physical, psychological, physiological, sociological, and the spiritual health. The result of these questionnaires helps an individual or an organization to know as to what are the areas where one needs treatment or care as far as health is concerned.

Sample Health Assessment Questionnaire

Name of the respondent:

Age of the respondent:

Gender of the respondent:

Marital Status:

Contact No.:

Correspondence Address:

Following are a few questions asked to assess your health conditions. Please answer all the questions in the spaces provided.

1. Please select out of the following list, all the illness, diseases or medical conditions that you are suffering from at present

a) Diabetes

b) Health conditions

c) Kidney problem

d) Liver malfunction

e) Migraine

f) Stomach issues

g) Intestinal problems

h) Cancer

i) Other( please mention the name)

2. Please select out of the following list, all the pains you are suffering from at present.

a) Headache

b) Joint pain

c) Stomach ache

d) Body ache

e) Other(please specify)

3. Does your family have a history of any particular illness, pain, disease or other medical condition? If yes, then please mention it in detail giving account of the medication taken for it.



4. How frequently do you visit doctor for a regular health check up?

a) Rarely

b) Every 6 months

c) Every 3 months

d) When needed

5. Are you taking any medication for anything? If yes then please provide the details below?


6. Do you exercise regularly?

a) Yes

b) No

7. Do you consider yourself as a healthy individual?

a) Yes

b) No