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.

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

Sample Medical Questionnaire Template

Medical Questionnaire Template

Download 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