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
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?
Q2. Do you feel any kind of physical and mental illness?
- Yes. Sometimes
Q3. Are you diagnosed with any of the following health issues?
- 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
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