A health care preferences questionnaire is one that is obtained by a government department to assess the physical and mental health of an individual. The information obtained by the questionnaire is kept strictly confidential and not shared with any one without the express permission of the individual answering the questionnaire.

The candidate taking the questionnaire should provide information regarding the standard of living in terms of health and wellbeing.

Sample Health Care Preferences Questionnaire

Name of candidate:-

Phone number:-

Mailing Address:-

Email Id:-

1. What do you think about your general health condition?

a) Excellent

b) Good

c) Average

d) Poor

2. Please specify the below mentioned activities that you are able to do at present without any symptoms of pain or breathlessness.

a) Moving a table or chair

b) Climbing many steps at a time

c) Pushing or moving household things

d) Indulging in walking or jogging

3. Have many times have you missed work in the past one month due to illness that has lasted for more than three days?

a) Once

b) Twice

c) Thrice

d) More than thrice

4. How many times have you felt sad, depressed or anxious during the last one month?

a) Once

b) Twice

c) Thrice

d) More than thrice

5. Please specify how many times in the last month have you felt completely exhausted and drained of all your energies that has led you to discontinue doing even routine activities?

a) Once

b) Twice

c) Thrice

d) More than thrice

6. Do any of your parents or blood relatives ever suffered or diagnosed with any of the following ailments?

a) Blood sugar

b) Thyroid

c) Lung disease

d) Cancer

e) Heart disease

f) High blood pressure


7. Do you think being healthy at all times is very important?

a) Yes

b) No