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.

“You can Download the Free Health Questionnaire¬†Template form, customize it according to your needs and Print. Health Questionnaire¬†Template is either in MS Word, Excel or in PDF.”

Sample Health Questionnaire Template

Health Questionnaire Template

Download 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