A medical evaluation questionnaire is used for evaluating the medical condition of a patient in a hospital prior to the patient’s treatment. Such a questionnaire is used for getting personal information regarding a patient’s health, since it helps the doctor to know about the allergies to which a patient might be prone to.
A medical evaluation questionnaire contains multiple questions based on the health of a patient and these questions can be subjective or multiple choice in nature. In order for you to have a better understanding of such a questionnaire, given below is a sample of medical evaluation questionnaire.
Sample Medical Evaluation Questionnaire:
Date of filling the questionnaire:
Date of birth:
Phone no. /mobile no. :
Give answers for the following questions and in case of multiple choice questions, tick mark one option.
Q1. Do you have any of the following allergies?
- Skin allergy
- Eye allergy
- Dust allergy
- Drug allergy
- Food related allergy
- Any other (please specify) ___________________________
Q2. Have you ever had a surgery before? If yes, please specify the reason and cause for the surgery.
- Yes, _______________________________________________________________________________________________________________________________
Q3. What was the reason for your last visit to the hospital?
Q4. What is your blood group?
- O positive
- A positive
- B positive
- AB positive
- O negative
- A negative
- B negative
- AB negative
Q5. Have you ever had a blood test before?
Q6. Have you ever had a urine test before?
Q7. Do you have regular eye checkups?
Q8. How often do you visit your family doctor for regular checkups?
- At least once in a week
- Once in a month
- Once in a year
- None of the above
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