A health performance questionnaire is a kind questionnaire which is framed by health organizations of different areas to get feedback of the people about the healthcare services being provided to them. On the basis of the feedback or opinions of the public, the organizations decide whether or not the health performance of the area or the district is up to the mark.

A health performance questionnaire is really useful and helps the community or district benefit as a whole. Given below is a sample of a health performance questionnaire which can be used for reference by anyone.

Health Performance Questionnaire Sample

Respondent’s name:

Respondent’s residential address:

Respondent’s contact number:

Respondent’s date of birth:

Respondent’s gender:

Marital status of the respondent:

Number of family members:

Please answer the following given questions which are part of a health performance questionnaire. Kindly answer in the spaces provided.

Q1. How often does your community conduct health checkups?

a) Every six months

b) Every year

c) Every 2 years

d) Other(please specify)

Q2. Do you get easy access to medical clinics and health facilities within your area?

a) Yes, very easy

b) Yes, but it takes some effort to get the facilities

c) No

Q3. How would you rate the medical facilities that are provided to you?

a) The quality of the services are excellent

b) The quality of the services is good

c) The quality of the services is average

d) The quality of the services is not acceptable

Q4. To what extent do the community authorities or medical organizations of the area go to ensure that everyone gets good medical facilities and health checkups?

a) They try hard to ensure the medical well being of all

b) They do not make an effort to solve our medical problems

Q5. Do you receive monthly medical newsletters?

a) Yes

b) no