Forms > Health Questionnaire Form

Health Questionnaire Form

A Health questionnaire form is used by medical insurance provider companies to analyze the applicant’s health condition before approving the insurance cover. The nature of questions in these forms is on scoring system where the candidate has to gain a certain level of marks to prove the normal health condition. Below shown is a sample health questionnaire form, the fields may vary according to different criteria of companies.

Sample Health Questionnaire Form

Personal Information

Full Name__________________

Date of Birth_________________

Age_________ Sex_________

Height________ Weight________

Full Mailing Address ______________________

Phone Number__________________

Email-ID__________________

Health Information

Provide the correct information for below questions regarding pervious and current diagnosis of diseases and medical treatments.

Immunization History____ BCG________ Measles______Polio_________

Hepatitis B________Dephtheria ___________

Describe those health problems that you had in last one year or more____________________________________________

Any chronic dieses problem, provide details if any________________

Are you addicted to drugs or alcohol___________________?

Do you already have a medical insurance cover or applied for it in past, if any provide details______________________

Related Posts:

Category: Questionnaire Forms

Sample Forms

What is a Form What factors should be considered while drafting Form What are the different types of Form What type of information should a form ask What is a accounting form What is a affidavit form What is a application forms? What is a appraisal form What is a assessment form What is a [...]

How to Write a Complaint Form

How to Write a Complaint Form

In today’s age of consumer awareness, it has almost become an imperative for any entrepreneur to establish a healthy professional relationship with the customer and pay heed to their likes and dislikes. One of the manifestations of this need is the complaint form that is issued by business organizations to offer their customers a platform [...]

How to Write a Business Form

How to Write a Business Form

Business forms are used by corporate organizations to notify prospective investors of the merits and demerits of the multifarious operations held under the purview of the concerned business organization. These are important official documents bearing crucial pointers about the preparation of business invoice, checklists, progression graphs and all such relevant information that would provide one [...]

How to Write a Bill of Sales Form

How to Write a Bill of Sales Form

The purpose of a bill of sales form is to report the sale of a certain product to a particular customer. These are legal documents that are extensively used in business these days to avoid sales complications as it acts as an evidence for the transfer of ownership of a particular item from the seller [...]

How to Write a Bankruptcy Form

How to Write a Bankruptcy Form

Bankruptcy forms are actually legal documents providing information about a given individuals financial condition when one needs to file for bankruptcy. The form vouches for the honesty of the concerned individual and substantiates his claim. They are can be either issued by an attorney or by the concerned individuals. Depending on the case or extent [...]