A Medicare questionnaire form is a form that an individual needs to fill in case he wants to enrol in a medical centre of a hospital. These types of forms include the details of the person and various questions regarding his health and medical history.
Sample Medicare questionnaire form
MEDICARE QUESTIONNAIRE FORM
Name of patient: ______________ Date of birth: ___________
Gender: ________________
Address: ____________________________________________
Mobile phone number: ________________________
E mail id: ________________________
- Do you receive any kind of health treatment?
a) Yes
b) No
- If yes, what kind of health treatment do you receive?
____________________________
- How often do you receive such health treatment?
a) Once in a week
b) Once in a month
c) Once in a year
d) Other (please specify): ________________
- Give a list or write down in detail all the medicines that you have to take on a regular basis.
__________________________________
- What is the current health related problem that you are facing that made you decide to enrol in our medical centre for treatment?
___________________
- Did you ever undergo any of the following treatments?
a) Kidney transplant
b) Cardio bypass surgery
c) Cancer treatment
d) None of the above
- Do you have a health insurance policy? If you do, please mention the insurance company name and the policy number.
______________________________
I assure that the above information is true and accurate. I also understand that any misinformation provided by me can lead to problems and I hold myself responsible for any misinformation.
Signature: _______________
