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Contactless health check survey template

Use a free contactless health check survey template for patients that are hesitant to visit a clinic or hospital. This sample questionnaire collects patient details, medical history, and lifestyle data to help doctors know more about the patient's condition.

Healthcare organizations can use the contactless health check survey to save time and offer more face time to patients. This questionnaire also helps overcome the fear of COVID-19 infection. It is ready to be used for any health check, however you can also customize as per your needs.

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Personal details:

First Name

Last Name

Phone

Email Address

Address Line 1

Address Line 2

City

Zipcode

Age:

Gender:

Male

Female

Others

Prefer not to say

Height:

Weight:

How would you rate your health?

How would you describe your physical health?

In good physical health (No illness or disabilities).

Mildy physically impaired (Minor illness or disabilities)

Moderately physically impaired (Requires substantial treatment)

Severely physically impaired (Requires extensive treatment)

Totally physically impaired (Confined to bed)

Lifestyle

How often do you have below in a week?

0

70

Smoke

Alcohol

Weeds

Other illicit drug

How many hours of sleep do you have each day?

0-3

4-5

6-8

9-12

12+

How often do you exercise in gym per week?

Never

Once in a while

About half the time

Most of the time

Always

How often do you engage in light physical activity at home per day?

Never

Once in a while

About half the time

Most of the time

Always

How many hours do you spend out in the sun per week?

0-2

3-5

6-10

11-15

15+

Medical history

Do you suffer from any chronic illness?

Yes

No

Are you suffering from any of the below?

Hypertension

Cancer

Diabetes

Cardiovascular disease

Asthma

Arthritis

Parkinson's disease

Other

Have you experienced any of the below in the last 24 hrs?

	No	Slight	Medium	Heavy
Cold	No	Slight	Medium	Heavy

Fever	No	Slight	Medium	Heavy

Cough	No	Slight	Medium	Heavy

Shortness of breath	No	Slight	Medium	Heavy

Headache	No	Slight	Medium	Heavy

	No	Slight	Medium	Heavy
Muscle pain	No	Slight	Medium	Heavy

Sore throat	No	Slight	Medium	Heavy

Diarrhea	No	Slight	Medium	Heavy

Loss of taste	No	Slight	Medium	Heavy

Loss of smell	No	Slight	Medium	Heavy

Do you take any health-supplement on a regular basis?

Yes

No

Do you take any prescribed drug on a regular basis?

Yes

No

How often do you get a health check-up?

Once in 3 months

Once in 6 months

Once a year

Only when needed

Other

Do you have any other health condition or information to disclose?

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