Sample Health Questionnaire

June 13, 2011

This sample health questionnaire can be used by a company or health facility to find out the relative health of an individual.  It can be used as anexample of the type of questions that are asked.  The format is pretty clear and the questions easy to understand and therefore easy to answer.  The questionnaire can be used by a company wanting to find out the health and fitness of a prospective employee.  The information gathered however cannot be used to discriminate against an individual as this is against the law.  A healthcare specialist can be used in the survey.

Name: ___________________________________

Address: _________________________________

Telephone: _______________________________

Mobile: __________________________________

Email: ___________________________________

Name of company: __________________________

Address: __________________________________

Job title: __________________________________

Department: _______________________________

Date of last health check: ______________________

Name of facility: _____________________________

Please indicate with a yes or no, any and all ailment(s) you have or do suffer from:

Diabetes:

____________________________________________

High blood pressure:

_____________________________________________

Asthma:

_____________________________________________

Stroke:

_____________________________________________

Heart attack:

_____________________________________________

Epilepsy:

_____________________________________________

Back ache:

_____________________________________________

Kidney problems:

______________________________________________

Depression:

______________________________________________

Mental illness:

______________________________________________

Allergies:

_______________________________________________

Skin conditions:

_______________________________________________

Other (please specify):

_______________________________________________

Do you suffer from any ailment (s) that could affect your ability to work effectively? ________________________________________________________________________

If so please specify the ailment:

________________________________________________________________________

Are you under any prescription medication? ____________________________________

If so please specify: _______________________________________________________

Have you ever been operated on? ____________________________________________

If so please answer the following:

Date of operation? ________________________________________________________

Reason for operation: ______________________________________________________

Respondent’s signature: _______________________ Date: ___________________

You declare all information is truthful.

Download Sample Health Questionnaire in Word Format

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