A medical treatment questionnaire is the one which is filled by the patients in a hospital, in order to evaluate whether or not the treatment given to them helped in improving their health. Such a questionnaire helps the doctor to know, if the treatment provided by them is beneficial for the patient or not.

Such a questionnaire may contain multiple choice questions as well as subjective questions. All these questions are related to the last medical treatment that the patient got in the hospital. Given below is a sample of such a medical treatment questionnaire which can be referred by you for future purpose.

Sample Medical Treatment Questionnaire:

Name of the patient:

Name of the doctor who treated you:

File number:


Gender: M/F


Date of birth:   (dd/mm/yy)

Residential address:

City/pin code:

Telephone number:

Patient’s email id:

Q1. What was the last illness you were suffering from, for which you got treated in the hospital?

  • Heart related problem
  • Lung problem
  •  Minor fever
  • Cold and cough
  • Skin problem
  • Dental issue
  • Any other serious illness

Q2. Have you been coming regularly for your medical checkups?

  • Yes
  • No
  • Sometimes
  • Very rarely

Q3. Give names of the medicines which were recommended by the doctor for your treatment?

  • ______________
  • ______________
  • ______________
  • _______________

Q4. Did you experience any negative side effects of your treatment? If yes, then explain briefly those side effects.

  • Yes, _______________________________________________________.
  • No

Q5. Are you satisfied with the treatment which your doctor recommended?

  • Very satisfied
  • Average satisfied
  • Not so satisfied
  • Do not approve of the treatment

Q6. Do you want to consult any other doctor for your check up?

  • Yes
  • No

Q7. Are you taking the preventive measures recommended by your doctor?

  • Yes
  • No
  • sometimes