Health Status Questionnaire Form
A Health status questionnaire form is usually used by doctors to make a correct judgment of an individual’s health. This form contains various questions regarding health condition, previous illness, present medical treatments and many other such things. The person who is filling this form is expected to provide correct information so that the physician can prescribe the right medical services to the person.
Sample Health Status Questionnaire Form
Personal Information
Name________________
Age_______ Sex________ Weight_______ Height__________
Address_____________________
Phone Number____________ Email-ID_____________
Health Status Questionnaire
Q 1. Do you have heart problem, if yes than since when?
_________________________________________
Q 2. Do you have any metabolic related problem?
________________________________________
Q 3. Are you suffering from diabetes, if yes than provide details?
_____________________________________________
Q 4. Do you have respiratory problems/illness?
______________________________________________
Q 5. Do you have muscular pain/joint pain problem?
_______________________________________________
Q 6. Is there any history of cardiac/pulmonary disease in your family?
______________________________________________
Q 7. Provide details of your present medical treatments/precautions?
______________________________________________
Q 8. List all your weekly physical activities/actions?
______________________________________________
Category: Questionnaire Forms

