Medial Questionnaire Form
A medial questionnaire form, as the name suggests, is a record document widely used by the patients and people in order to obtain health check- up records by answering the simple medial questions. Such a form can be filled at medical clinics, health institutions and hospitals.
Sample Medial Questionnaire Form:
Details of the patient:
Full name: __________________
Date of birth: ____/ ____/ ____ Age: _________ Sex: ______
Blood group: ______________
Record address: ___________________________________
Phone number: ___________________________________
Social security number: ____________________________
Q1. What is the purpose of filling this medical questionnaire?
- General health check- up
- Medical treatment
- Obtaining medical certificate for official use
- Others, please specify: ______________
Q2. Are you suffering with any of the following common health symptoms nowadays?
- Cough & cold
- Mild fever
- Headache
- _______________
Q3. Have you ever met with any accident?
- Yes. Please mention the details: ________________
- No
Q4. Do you have any of the following health problems?
- High blood pressure
- Low blood pressure
- Diabetes
- Others: _______________
Q5. Have you enclosed all your medical reports for the above chosen purpose?
- Yes
- No
- Other remarks: _________________
For official purpose only:
Signed by the patience: ________________
Signature of the parents/ guardian if the patient is a minor: _______________
Signed by the concerned physician/ doctor/ transcriptionist: _______________
Seal of the hospital/ nursing home/ clinic: ____________________
Download Medial Questionnaire Form
Category: Questionnaire Forms
