A medical symptoms questionnaire is used by medical practitioners to evaluate patient regarding various symptoms of a disease or illness. The objective of using this questionnaire is to determine whether the patient has any health hazards or not and the kind of lifestyle he leads. It also examines the patient’s response to a therapy.

Sample Medical Symptoms Questionnaire:


  1. Do you suffer from any of the following weaknesses?

a)   Headaches

b)   Insomnia

c)   Dizziness

d)   Faintness

e)   None

  1. Do you have any of the following issues in your eyes?

a)   Itching sensation

b)   Swollen or reddened eyelids

c)   Dark circles or bags under eyes

d)   Blurred vision

e)   Burning sensation

f)    None

  1. Is there any itching or loss of hearing problem in your eyes?

a)   Yes

b)   No

  1. Do you face any of the following problems in your nose?

a)   Stuffy nose

b)   Excessive Sneezing attacks

c)   Sinus problems

d)   Mucus formation

e)   Hay fever

f)    None

  1. Is there any of the following issues in your mouth or throat?

a)   Chronic coughing

b)   Discolored lips, tongue or swollen lips and gum

c)   Canker sores

d)   None

  1. Do you have any of the problems with your skin?

a)   Acne

b)   Hair loss

c)   Rashes or dry skin

d)   Flushing, hot flashes

e)   Excess sweating

f)    None

  1. Have you faced any of the problems due to your digestive tract?

a)   Vomiting or nausea

b)   Bloated feeling

c)   Heartburn

d)   Diarrhea

e)   Constipation

f)    Belching or passing excessive gas

g)   Stomach ache or intestinal pain

h)   None

Patient Name: Howard Mayer

Dated: 24th November, 2010