[Type here]
Health Screening
Questionnaire
The information you provide to complete the questionnaire is
strictly confidential
Name:
What gender are you? What age group are you?
Male Female 15-25 26-35 36-45
46+
Address:
Postcode:
Tel no: D.O.B: Occupation:
Are you on If yes, what?
Medication:
Y/N
Do you If yes, how Do you drink If yes, how
smoke? often? alcohol? often?
Y/N Y/N
Are you pregnant? Y/N Do you have a disability? Y/N
Have you had any problems during How does that disability affect your
your pregnancy? Y/N health and learning?
Number of children?
Do you use any aids to support you?
Y/N
Health Screening
Questionnaire
The information you provide to complete the questionnaire is
strictly confidential
Name:
What gender are you? What age group are you?
Male Female 15-25 26-35 36-45
46+
Address:
Postcode:
Tel no: D.O.B: Occupation:
Are you on If yes, what?
Medication:
Y/N
Do you If yes, how Do you drink If yes, how
smoke? often? alcohol? often?
Y/N Y/N
Are you pregnant? Y/N Do you have a disability? Y/N
Have you had any problems during How does that disability affect your
your pregnancy? Y/N health and learning?
Number of children?
Do you use any aids to support you?
Y/N
