Health Survey Questionnaire

June 28, 2011

A health survey questionnaire is a set of questions that are put together for use in the medical field for medical assessment.
A health survey questionnaire focuses on any or all aspects of a person’s medical history in particular a person’s ability to operate.
A health survey questionnaire contain questions that relate to a person’s probability of using medications or having ailments that could lead to impairments and a general lack of awareness, concentration and mobility
Once the medical questionnaire has been filled and a person’s fails to meet the required medical standards then the person is said to be ailing.
Sample Health Survey Questionnaire
Below is an example of a health survey questionnaire for an elderly person.
1.    If you were to evaluate your health. What would you say?
____________________________________________________
1.    How often do you go for your medical check ups?
_____________________________________________________
1.    Do you live alone, or with a spouse or relative?
____________________________________________________
1.    Are you able to perform everyday activities? If not give reasons why
_______________________________________________
2.    Are you able to walk distances?
______________________________________________
Describe your daily diet.
________________________________________________
1.    Do you feel you have a problem remembering things?
____________________________________________________
1.    Are you able to care for yourself?
_______________________________________________
1.    Which medications are you currently taking?
__________________________________________________
1.    How frequently do you have to take the medication?
__________________________________________________
1.    Have all the medicines you take been prescribed by a pharmacist? Name those that are not prescribed.
___________________________________________________
1.    Describe a typical day for you.
____________________________________________________
1.    How old are you?
___________________________________________________
1.    Gender
o    Male
o    Female

Download Health Survey Questionnaire in Word Format

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