Health Check Questionnaire

June 13, 2011

A health check questionnaire is a simple and fast way to provide information about one’s health and facilitate access to a health action plan for future use. The questionnaire should indicate that confidentiality is guaranteed and assure people that their responses will not be revealed to third parties. This makes it easier for the respondents to maintain an honest approach to the health check questionnaire. The questionnaire should contain well structured questions that are easy to understand and respond to. It helps to keep track of a person’s overall health and wellbeing by venturing into the person’s health history, background and current condition.

Sample Health Check Questionnaire

The information provided in this form is strictly confidential.

Name…………………………. Sex…………………………………Date of Birth…………..

Address…………………………………………………..

E-Mail…………………………………………………….

Phone Number…………………………………….

Have you ever been treated for a heart related condition?  ………………………………………….

Does physical exertion cause you any pain?  ………………………………………………………………….

Do you experience pain even during periods of rest?  …………………………………………………….

Have you ever felt dizzy or weak?  ………………………………………………………………….

Are you on medication for hypertension?  ……………………………………………………

Do your joints ache after physical activity?  ………………………………………………….

Has any medication been presently prescribed to you?  ………………………………………………..

Are you expecting a child or lactating?  ……………………………………………………………………………..

Can you exercise without medical supervision?  ………………………………………………………………..

Are you aware of your blood pressure?  …………………………………………..

If yes, please note it here……………………………………………………….

Are you a regular smoker?  ………………………………………………………………..

If yes, how often do you smoke?  …………………………………………………..

Do you have a family history of heart disease?  ………………………………………………..

What is your cholesterol level?  ……………………………………………………………….

What level of physical activity is comfortable for you?  …………………………………..

Date………………………………………………     Signature…………………………]

Download Health Check Questionnaire in Word Format

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