A health interview survey questionnaire is one that is conducted in order to find out the level of health maintained by people belonging to a specific locality. The primary objective of this questionnaire is to recognize the critical illnesses faced by people and the level of medical attention available to them during the period of sickness.

This questionnaire helps to obtain crucial information about availability of medical services and addition of better ones for the well being of the entire group of people included in the survey questionnaire.

Sample Health Interview Survey Questionnaire

Name of the individual :

Full mailing Address :

Contact number :

Age :

Gender :

1. How many adults are there in your household?


2. How many children are there in your household?


3. How many times in a year do you visit your doctor for a regular check up?


4. Do you or any of your family members suffer from any kind of vision, hearing or mobility impairment/

a) Yes Pl specify kind of disability ____________

b) No

5. Please specify the number of members in your family who are dependants?


6. Do any of your family members suffer with any of the following health ailments as specified below?

a) Respiratory problems

b) Seizures

c) Allergies

d) Severe Injury

e) Food poisoning

7. Do you and your family members maintain a healthy lifestyle that includes moderate physical activity and intake of nutritious food?

a) Yes

b) No

8. Do you or any of your family members smoke or consume alcohol every day?

a) Yes

b) No

9. Have you been diagnosed with any of the diseases specified here under?

a) Diabetes

b) Blood cholesterol

c) Blood pressure

d) Cognitive diseases

10. Have you or any of your family members taken health insurance to cover for medical expenses and also specify the kind of health insurance if obtained?