Sample Questionnaire

July 3, 2010

SAMPLE HEALTH QUESTIONNAIRE

Filed under: questionnaires — questions @ 12:57 pm

A sample health questionnaire is that which consists of several questions related to the health of a prospective employee. These questions are used by an organization to inquire about the fitness level and health condition of the prospective employees .These questions are very simple and straightforward .These questions are posed generally in the presence of a medical practitioner.

Below is a sample questionnaire on health:

Name of the candidate: ___________________________________

Address of the candidate: _________________________________

Telephone no of the candidate: _______________________________

Mobile no of the candidate: __________________________________

Email id of the candidate: ___________________________________

Name of company: __________________________

Company address: __________________________________

Job position you are working on: __________________________________

Department you are working in: _______________________________

When did you have your last health check up?: ______________________

Where did you have your last health check up?: _____________________________

Write YES if you suffer from the given ailment otherwise write NO:

a.)    High diabetes:____________________________________________

b.)    Abnormal blood pressure:__________________________________

c.)    Night Blindness:_____________________________________________

d.)    Respiratory problems:_____________________________________________

e.)    Heart problem:_____________________________________________

f.)     Color blindness:_____________________________________________

g.)    Back ache:_____________________________________________

h.)    Lever problems:______________________________________________

i.)      Depression:______________________________________________

j.)      Mental illness:______________________________________________

k.)    Skin allergies:_______________________________________________

l.)      Headache:_______________________________________________

Any other ailment (please mention):

_______________________________________________

Do you think any of your ailments can affect the quality of work that you do? ________________________________________________________________________

If yes then  please mention the ailment:

________________________________________________________________________

Have you taken any medicines for your ailment? ____________________________________

If yes please specify what medicines: _______________________________________________________

Have you ever undergone an operation? ____________________________________________

If yes please answer these questions given below

The operation Date

________________________________________________________

Was the operation successful? ______________________________________________________

Signature: _______________________ Date: ___________________

I hereby declare that all that I have submitted are true to my knowledge

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