A health demographics questionnaire is one that is served to a specific set of target population with a view to assessing the health condition of the target population in question.

This questionnaire aims to identify the various diseases and health conditions of target population apart from understanding the various environmental and lifestyle factors responsible for the health condition. It also aims to identify the vital health statistics that help in disease prevention.

Sample Health Demographics Questionnaire

Name of the person taking the questionnaire:-

Complete mailing address:-

Phone number:-

Email address:-

1. How many members are there in your family including aged persons and children?


2. Are there are family members that suffer from acute medical conditions due to which they are immobile?

a) Yes

b) No

3. Are there any of your family members who has become impaired or is having restricted physical activity due to an accident or physical injury?

a) Yes

b) No

4. Do any of your family members suffer from chronic health conditions?

a) Yes

b) No

5. When is the last time you or any of your family member has undergone a complete medical examination?


6. Have you or any of your family member been hospitalized in the past one year?

a) Yes

b) No

7. How many times have you made use of the medical assistance of the state or private health insurance for illness suffered by you during the last one year?


8. Have you or any of your family members suffered from any of the following diseases in the past one year?

a) Common cold

b) Bronchitis

c) Pneumonia

d) Influenza

9. Did you or any of your family members suffered with any of the musculoskeletal conditions as specified here under?

a) Fractures and dislocation of bones

b) Sprains or strains

c) Contusions or injury

d) Open wounds or lacerations