Medical Screening Questionnaire

June 20, 2011

Medical screening questionnaire is used to acquire basic information about a patient before further examination is done. The medical screening questionnaire contains general questions that a person is asked in order to get the basic stats of an individual. This information may lead to further diagnosis of the person who is ill. Every medical examination begins with a screening especially for a new patient. It is a confidential screening that is also done to check possible presence of medical problem in some special circumstances like sports, traveling and buying insurance policies among others.   A sample medical screening questionnaire is below.
Sample Medical Screening Questionnaire

Patient Information


Date of Birth _______________________________________

Address ______________________________________________

Telephone Number ___________________________________________

Doctor’s name if registered with one _____________________________________
Emergency Information

Name ______________________________________________________________

Relationship _______________________________________

Telephone number _____________________________________
Specific Information:

Personal Health History (Answer Yes/No)

1.Have you been given medical treatment in the past two years? ________________________________________

2.Have you had surgery in the past three years? _______________________________________

3.Is your heart on regular or irregular heartbeat? __________________________________________

4.Are you currently undergoing any treatment or under observation? _________________________________________

5.Do you have any terminal disease? _________________________________________

6.Do have any chest problems? _____________________________________

7.Are your organs all functioning well? ___________________________________________

8.Have you hade any injuries in the past five years? ____________________________________________

9.Does your family have a history of any genetic disease? _____________________________________________

Have you ever fainted or had a concussion? ______________________________________________
Do you have any allergies? If Yes, kindly list them ______________________________________________

I have read and fully understood the form and have given accurate information in regard to my health.

Signed (patient) _______________________ Date ________________

Signed (examiner) _____________________ Date _______________

Download Medical Screening Questionnaire in Word Format

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