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:

Patient’s name:


Date of birth:

Gender: M/F

Residential address:

Phone no. /mobile no. :

Email id:

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.

  • No
  • 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?

  • Yes
  • No

Q6. Have you ever had a urine test before?

  • Yes
  • No

Q7. Do you have regular eye checkups?

  • Yes
  • No
  • Sometimes
  • Rarely

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