Medical questionnaire questions are created in such a way that they throw light on a patient/participants current medical condition and medical history. This type of medical questionnaire provides an insight into various patient conditions and this information can be referred to by medical institutions when a patient in admitted or during routine physician’s check up.
Sample Medical Questionnaire Example:
Name of the patient: ____________________________
Last date of checkup: _______________________________
Q1. What type of medical checkup did you undergo recently? Please mention the details.
- Date of check up:_________________
- Physicians Name:_________________
- Medical Institution:________________
Q2. Do you suffer from any specific skin allergies? If yes then please provide the type of allergy and medication
Q3. How often do you visit your physician for a routine check up?
- Once a month
- Once a quarter
- Once in 6 months
- Once in a year
- Don’t know
Q4. Are currently on any specific medication? If yes then please specify name of the medication and what it is for
- Medication: ____________________________
- Medical Condition:____________________________
Q5. Do you own a medical insurance policy? If yes, please mention policy number and what it covers?
- Insurance Policy Number:
Q6. Do you suffer from a disorder or medical condition in the following areas?
- Blood Sugar
- ENT (Ear,Nose,Tongue)
Q7. Have you undergone any surgery in the near past? If yes, then please mention type of surgery and post surgery treatment.
- Type of Surgery:_______________________
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