Health questionnaire MEDICAL QUESTIONNAIRE MEDICAL QUESTIONNAIRE First Name: * Last Name: * Full Name: * Companion: Phone: * Email: Sex: * Male Female Date of Birth: * Age: * Marital Status: * Single Married Separated Divorced Widowed Children: Total #: # Living: Total # Living in Household: Type of Living Place: Nuclear Family Joint Family Hostel/Dormitory Alone Religion: Christian Hindu Jewish Muslim OtherOther Denomination: Highest Education Completed: Primary School: 1st – 5th Standard 6th – 10th Standard 11th – 12th Standard HS Graduation Diploma Postgraduate Doctorate Employment Status: Student House Wife Employed Retired Unemployed Self-Employed Occupation: Do you use your phone to connect to internet? Yes No Next
