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: ____________________________

Address: ________________________________________

Age: ___________

Gender: ________________

Email: ______________________

Physicians Name:__________________________________

Last date of checkup: _______________________________

Q1. What type of medical checkup did you undergo recently? Please mention the details.

  • Type:_____________________
  • Medication:_____________________
  • 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

  • Yes
  • No
  • Type:_____________________
  • Medicine:_____________________

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

  • Yes
  • No
  • Medication: ____________________________
  • Medical Condition:____________________________

Q5. Do you own a medical insurance policy? If yes, please mention policy number and what it covers?

  • Yes
  • No
  • Insurance Policy Number:
  • Cover:

Q6. Do you suffer from a disorder or medical condition in the following areas?

  • Blood Sugar
  • Cholesterol
  • Liver
  • Kidney
  • Heart/lungs
  • Abdomen
  • 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.

  • Yes
  • No
  • Type of Surgery:_______________________
  • Treatment:____________________________