Health Questionnaire Template

June 30, 2011

A health Questionnaire template is a ready to use questionnaire which is used to assess various health related issues. These templates can be used to record the health facility of an organisation or can also be used to assess the health condition of an individual.

Sample Health Questionnaire Template:

Name of the patient: ________________
Date of birth: ___/ ____/ ____
Sex: ____________________
Occupation: _____________
Date: ___/ _____/ ____ [the participant will provide the necessary details]
Q1. Are you feeling any kind of weakness and physical problem nowadays?
•    Yes
•    No
Q2. Do you have any of the following health problems?
•    High blood pressure
•    Low B.P
•    Diabetes
•    Low blood cell count
Q3. Are you seeking any treatment for any of the following diseases?
•    Cardiovascular problem
•    Heart stroke
•    Brain disorder
•    Depression
Q4. Do you visit any doctor for your monthly check up?
•    Yes
•    No
Q5. Are you taking your medicines regularly?
•    Yes
•    No
Q6. Would you like to change your doctor?
•    Yes
•    No
Download Health Questionnaire Template in Word Format

Leave a Comment

Previous post:

Next post: