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 demographics, vital signs, travel history, symptoms, and existing conditions across 16 questions on roughly two pages, so front desk and clinical staff can capture a consistent record for every patient.
What this survey measures
The form starts with patient demographics: name, date of birth, age, ethnicity, and blood type. It then records the patient's temperature and recent travel, including trips outside the country and contact with anyone who has travelled to an area with a known outbreak. A symptom section covers influenza-like illness, a grid of symptoms with how many days each one lasted, and a checklist of chronic conditions such as asthma, diabetes, and cardiovascular disease. Closing items ask about flu vaccination, recent foreign travel, and how the patient is feeling today, with an office-use section for staff notes.
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, temperature, 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 temperature units, and the paper layout reflows automatically to fit your edits.
Preview the PDF above, or use this template to start collecting responses today.