A medical assessment questionnaire helps medical authorities or health centers to assess the medical health of patients or other people. These questionnaires are used by health clinics or medical organizations to gather information about the health of people and have collective information of the health of a group, or employees of a company or students of a school etc.

These questionnaires have questions which ask for the basic health or medical information of the respondents. If you are looking for a referential document, then the following given sample of a medical assessment questionnaire would be really useful for you.

Sample Medical Assessment Questionnaire:

Name of candidate:

Age of candidate:

Date of birth of candidate:

Gender of candidate:                                           (male/female)

Mobile phone number:

Residential address:

Email address:

The following is a medical assessment questionnaire. This will take only a few of your minutes. So please answer all the questions.

Q1. What is your blood group?

a)      A+

b)      B+

c)      AB+

d)     O+

e)      A-

f)       B-

g)      AB-

Q2. Are you allergic to many material, objective, food item etc?

a)      Yes

b)      No

Q3. If yes, then pick the suitable allergy type.

a)      Skin allergy

b)      Allergic to a certain food item

c)      Allergic to dust

d)     Allergic to pollutants

e)      Allergic to certain smells

f)       Other

Q4. Have you ever had any accident that left a permanent damage?

a)      Yes

b)      No

Q5. Do you have perfect eyesight?

a)      Yes

b)      No

Q6. Have you ever had any operation or surgery?

a)      Yes

b)      No

Q7. Do you have any difficulty in hearing?

a)      Yes

b)      No

Q8. Are you suffering from any disease or ailment at present?

a)      Yes

b)      No

Q9. How would you describe yourself?

a)      I am active and energetic

b)      I am lethargic and get tired easily