A medical questionnaire template is the important questionnaire document used in the health care organizations in order to record the initial level medical fitness of a person. Such a questionnaire plays a vital role during a medical fitness test conducted by the general physician.
Sample medical Questionnaire Template:
Name of the candidate: _____________
Date of birth: ___/ ___/ ___
Sex: ________________Age: ________________
Blood Group: _____________________________
Date: ___/ ___/ ___ [these basic details are filled by the concerned medical staff]
Q1. Are you suffering from any disease?
• Yes
• No
Q2. Do you feel any kind of physical and mental illness?
• Yes. Sometimes
• Yes
• No
Q3. Are you diagnosed with any of the following health issues?
• Diabetes
• Heart stroke
• Neurological disorder
Q4. How often do you visit your doctor for the health advice?
• One in a month
• Once in three months
• Once in six months
Q5. You have come here for the medical check up for:
• Official use
• Embassy use
• Treatment use
Download Medical Questionnaire Template in Word Format