Health evaluation is the assessment or evaluation of the current health status of an individual. Health evaluation questionnaire is one of the tools that is used by practitioners or doctors in order to conduct health evaluations of the individuals. The analysis of the answers helps in drafting out a course of medical treatment for the respective individual as per their health status.

Sample Health Evaluation Questionnaire





Contact No.:



Provide the answer to the following questions or fill in the blanks appropriately:

1. Give the details of the medical practitioner/ physician / doctor you are visiting (if any). Mention his/ her name, contact no. and correspondence address.


2. Have you had any major surgical operations in the past? If yes then mention the cause, the type and the medication/ other treatments given.


3. Under the following heads specify the particular name or kind of allergy you suffer from (if any). Also list the medication beside it.

a. Skin allergies ________________________

b. Food allergies ________________________

c. Animal allergies ______________________

d. Chemical allergies ____________________

e. ____________________________________, specify if any other.

4. Kindly select if you suffer from any of the following illnesses.

a. Diabetes

b. Indigestion

c. Ulcers

d. Acidity

e. Depression

f. Anxiety

g. Stress/ tension

h. Sleeplessness

5. Kindly select if you suffer from any of the following joint pains/ body aches:

a. Arthritis

b. Knee/ elbow joint pain

c. Head aches

d. Migraine

e. Muscle pain ____________, specify

f. Cervical pain

g. _______________________, specify if any other.

6. How often do you fall sick for example on an average of six months? And how long does it take you to recover from the illness?


7. Specify any family medical history of diseases or illnesses.


8. List any medications you are currently taking. Give specifications.