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Health Screening Questionnaire Template

Health screening questionnaire with 41 questions covering patient details, vital signs, travel history, symptoms, lifestyle, and health history. Print, hand out, and scan completed forms for instant results.

Questions: 41EnglishHealthcare and Care Homes

Print this ready-made questionnaire and hand it out, then scan and upload the completed forms to read the answers automatically. You can also share the same questionnaire online. The preview below shows the paper version.

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This health screening questionnaire is a printable intake form for clinics, occupational health teams, and study coordinators who need to record a patient's baseline health before a visit. It gathers patient details, vital signs, travel history, symptoms, lifestyle, and existing conditions across 41 questions on four pages, so front desk and clinical staff can capture a consistent record for every patient.

What this survey measures

The form starts with patient details: name, date of birth, age, sex, ethnicity, blood type, contact numbers, and whether an interpreter is needed. It then records temperature, height, weight, blood pressure, and pulse, along with recent travel and contact with anyone from an outbreak area or with a fever. The symptoms section asks how the patient feels today and, for anyone who had influenza in the past year, how many days each symptom lasted. A short lifestyle section covers general health, tobacco, alcohol, exercise, and sleep. The health history section lists chronic conditions such as asthma, diabetes, and heart disease, recent hospital stays and operations, flu vaccination, medicines, and allergies. The form closes with a comment box, a signed declaration, and a boxed office-use section for staff.

How to use it on paper

Print the questionnaire and hand it to patients at check-in, in the waiting room, or at a health screening station. Ask them to use a blue or black pen and mark answers clearly. Collect the completed forms and scan them with PaperSurvey to read every checkbox and written note automatically, so results land in your dataset without manual entry.

Customize this template

Most teams add their clinic logo, adjust the symptom and condition lists to match their specialty, and reword or remove questions that do not apply. You can add follow-up fields or change the measurement units, and the paper layout reflows automatically to fit your edits.

Preview the PDF above, or use this template to start collecting responses today.

Paper and web from one template

Use this questionnaire on paper, online, or both, and collect all responses in one place. Open it in a new tab. This is a preview only. Responses are not saved.

Questions in this template

  1. Patient name
  2. Date of birth
  3. **Age in years**
  4. Sex
  5. Ethnicity
  6. Blood type
  7. **Phone number**
  8. **Emergency contact**
  9. Do you need an interpreter?
  10. **Temperature in °C**
  11. **Height in cm**
  12. **Weight in kg**
  13. **Blood pressure, if known**
  14. **Pulse rate, if known**
  15. Have you travelled outside the country in the last 14 days?
  16. If yes, which countries did you visit?
  17. In the last 14 days, have you met anyone who had been in an outbreak area?
  18. In the last 14 days, have you been close to anyone with a fever?
  19. How are you feeling today?
  20. In the past 12 months, have you had influenza or an influenza-like illness?
  21. If you had influenza, how many days did you have each of these symptoms?
  22. How would you describe your general health?
  23. Do you smoke or use tobacco products?
  24. How often do you drink alcohol?
  25. How often do you exercise or do physical activity?
  26. How many hours do you usually sleep each night?
  27. Do you have any of the following conditions?
  28. Have you stayed in hospital in the last 12 months?
  29. Have you had an operation in the last 6 months?
  30. Do you have a long-term condition or disability that affects your daily life?
  31. Have you had a flu vaccination in the last nine months?
  32. Do you currently take any prescription medicine?
  33. Do you have any allergies?
  34. Please list any medicines you take and any allergies we should know about
  35. Please describe how you are feeling today and any concerns you would like to discuss
  36. Patient signature
  37. Date signed
  38. Recent illness or infection test
  39. Screening outcome
  40. **Staff initials**
  41. **Date checked**

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