health questionnaire

for daily medical practice


Health questionnaire for screening and prevention

Revision: 06.08.2012


Four main points:

• The patients accepted willingly this screening leaf easily printed.
• Without using it, many diagnosis were missed.
• Any doctor may verify by using it for alternate periods.
• Twelve questions help discerning with whom to talk about drinking.


This questionnaire was used by a general practicioner among 200 patients.
It provided 63 additional diagnoses, eleven of which were important.
112 other answers were of therapeutic, educational or psychotherapeutic value.

Among gastroenterological hospital outpatients, the greater the number of past diagnoses, the more additional disclosure was provided by the questionnaire.

The questionnaire also stimulated memory, as one patient out of three wrote unsolicited answers.
The questionnaire helped to identify something true among those looking like false patients; and truer facts in the true ones.

The duration of the verbal anamnesis is limited, especially because the great majority of answers are fortunately negative. When persevering with questions, the physician may appear stupid. The questionnaire prevents this risk.
It is in use since more than 20 years.

In GP's waiting rooms, most patients appeared surprised but only 10% refused the questionnaire. In hospital, only one out of 123 refused.
People accept written questions that they would consider insulting if spoken. Finally, they actively cooperate to their diagnosis. The deaf were the greatest beneficiaries.

In workplace medicine, the questionnaire was felt to be reassuring, resulting in a decrease in absenteeism.

The questionnaire also provides several opportunities for having a talk concerning alcohol.
There is no question about alcohol consumption but twelve questions frequently elicited positive answers from persons impaired by alcohol: sleep, tranquilizers, tiredness, anxiety, poor memory, depression, suicidal ideas, hypertension, gout, cramps, tremor and after-effects of accidents. These questions are marked by … before the ?
If so, the physician may remember the first question of the CAGE questionnaire:
Have you ever felt you should cut down your drinking? Or perhaps Have you ever felt we might consider together the place of alcohol in your life? Nice question to start a talk after the physical examination.

Many general practitioners or workplace physicians fear that they will be replaced by machines.
However, the questionnaire is only an aid for diagnosis. A yes answer is only a symptom, not a diagnosis, all the more as a yes is never a certainty.

In the case of treated alcohol dependence, the twelve questions mentioned above may be used as criteria of recovery.

Such a questionnaire is not suitable for epidemiology. It looks more at symptoms than diseases. The questions are voluntarily vague. They were selected according to the seriousness of omissions or of iatrogenic risks. Epidemiology would be better served by sample surveys than by daily registration.

How to use it?

The questionnaire is given to be filled out in the waiting room.
When the answer is no, the patient writes nothing.
When it is yes, the patient ticks after the question-mark.
If he is unsure, likewise, in order to discuss the question. The whole process lasts on average four minutes.

When the patient enters the consulting room, the physician leaves the questionnaire aside and starts as usual. Before the physical examination, the answers are discussed rapidly because they are not yes or no, but only yes.
If the answer is wrong, the physician crosses the tick out.
If the answer brings something new, he traces a circle around it.
The time for routine interviewing is decreased but the whole duration is increased slightly to clarify dubious points and to take advantage of the disclosures.

The following list may be printed on three columns on one side of a sheet, in Times New Roman or Arial condensed light 11 pts types, with 12 mm margins.

The websurfers are free to print questionnaires for themselves and for others and to bring a filled copy to their doctor.


- Besançon F, Chabin B, Toupin M : Valeur du questionnaire de santé en médecine de famille et en consultation hospitalière. Sem Hôp Paris 1984; 60 (9): 608-614
- Besançon F, Chabin B, Toupin M : L'épidémiologie, application accessoire des questionnaires de santé. Sem Hôp Paris 1984; 60 (9): 615-617



These questions are designed for the early screening of frequent diseases, or even risks that should not be neglected.
Your answers will be covered by medical confidentiality.




Age…  Height……    Weight… … kg Today's date…

• If your answer is NO, do nothing;
• If YES, tick after the ?
• If you are not sure, tick to discuss it with the physician.

Are you here for the first time?

Do you take any medication?

Sleeping pills or tranquilizers…?
Anticlotting drugs?

Do you have intolerance to drugs?
Any food intolerance?

Sick after an insect bite?

Had you ever undergone surgery?

Blood transfusion?

Do you sleep badly…?
Does noise disturb you?

Do you get tired easily…?

Anxiety, nervousness…?


Recent weight loss?

Vaccinations not up to date?
Attacks of fever?

Chest pains during physical
Chest pains when at rest?


High blood pressure…?

Abnormally short of breath?
Do your ankles swell?

Do you bleed too easily?

Persisting or frequent bronchitis?

Bloody spits?

Lumbago or sciatica?
Gout…? Uric acid?

History of phlebitis?

Jaundice, hepatitis?

Teeth: well supervised?
A gastric or duodenal ulcer?

Parasites or intestinal worms?
Difficult digestion?

Often constipated? False needs?
Do you use laxatives?

Red or black blood in stools?

Are you on a diet?

Do you faint easily?

Was your birth difficult?
Seizure or tetany?

Memory loss…?

A history of depression…?
Ever had suicidal ideas…?

Tremor, clumsy hands…?

Nephritic colic?
Pain when passing water?

Urinating several times at night?

Albumin in urine?

Diabetes, sugar in urine?
Often very thirsty?

Bouts of dizziness?

A buzzing sensation in your ears?
Early signs of deafness?

Prolonged colds or sinusitis?
Is your voice hoarse?

Trouble swallowing?
Swollen glands?

Exposure to toxic substances?
Over ten cigarettes/day?

After-effects of an accident…?

Likelihood of being HIV positive?


Bleeding between periods?
Late periods?

Excessive menstrual blood flow?
Need for contraception? Condom?

Breasts : Pain? Lump?

Cervical smears omitted?

Issued from the web page


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