Medical Questionnaire Template

June 30, 2011

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

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