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Survey Templates Health Care Surveys Contactless health check survey template

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.


Personal details:
Age:
Gender:
Height:
Weight:
How would you rate your health?
Physical health
Mental health
How would you describe your physical health?
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?
How often do you exercise in gym per week?
How often do you engage in light physical activity at home per day?
How many hours do you spend out in the sun per week?
Medical history
Do you suffer from any chronic illness?
Are you suffering from any of the below?
Have you experienced any of the below in the last 24 hrs?
Do you take any health-supplement on a regular basis?
Do you take any prescribed drug on a regular basis?
How often do you get a health check-up?
Do you have any other health condition or information to disclose?