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Medical Questionaire Marital Status (Please Tick One)

This medical questionnaire collects information about a person's marital status, gender, family planning, health conditions, illnesses, surgeries, addictions, family medical history, infections, and legal obligations. The respondent is single, male, has no children or plans to have children in the next year, and answers "no" to most health questions except using glasses.

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Kunal Singh Bisht
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59 views

Medical Questionaire Marital Status (Please Tick One)

This medical questionnaire collects information about a person's marital status, gender, family planning, health conditions, illnesses, surgeries, addictions, family medical history, infections, and legal obligations. The respondent is single, male, has no children or plans to have children in the next year, and answers "no" to most health questions except using glasses.

Uploaded by

Kunal Singh Bisht
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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MEDICAL QUESTIONAIRE

Marital status (please tick one)

Single ___*____ Married _________ Other (Divorcee/widow)________

Gender: Male _____*_____Female __________

Do you have any children?

Yes _______ No _____*___

If YES then kindly mention the number of children: _________.

If NO then, are you having any plans to conceive within a year?

Yes No *

Answer the following question with YES or NO

Do you have any physical disability? Yes No*

Do you use hearing aids or contact lenses/glasses? Yes No *

Do you have health insurance? Yes No *

Have you been treated for any major illness in the last 2 years?

Yes No *

Have you fallen sick in the past six months? Yes No *

If yes then kindly mention the type of sickness:_____________________________.

Have you been hospitalized for a period of 7 days or more in the past 5 years?

Yes No *

Have you undergone a surgery in the last 2 years? Yes No *

If YES then specify the date __________ and the type of surgery
undergone__________________________________________________________.
Do you suffer from:

HIV / any other STDs Yes No *

Hypertension/ BP Yes No *

Heart Diseases Yes No *

Epilepsy Yes No *

Diabetes Yes No *

Asthma Yes No *

Migraine Yes No *

Do you have any illness that requires you to be constantly on medication?

Yes No *

If yes then specify which one:________________________________

Have you ever been addicted to drugs or alcohol?

Yes No *

Does your family have a history of any of the following diseases?

Asthma _______

Heart disease _______

Cancer __________

Have you ever been infected by any waterborne diseases? Yes No *

If yes then mention which one:___________________

Allergies if any:

Are you under any legal obligation to your previous employer? Yes No *
If yes then please clarify_______________

THANK YOU

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