Sample Questionnaire

Questionnaire Regarding Health Insurance

Name: First name: _______ Middle name: __________ Surname:

_________
Address: Street address __________ City name ________ State name

_________
Postal code _________ Date of birth: ____________ Gender: __________ Residential Contact number: _____________ Mobile number: ________ Email id: ___________

 1. Do you have any kind of insurance? a) Yes b) No 2. If the answer to the above question is yes, what kind of insurance are you covered with? ________________________________________ 3. Does anyone else in your family have any kind of insurance? _________________________________________

4. Does your employer cover you with any kind of insurance? a) Yes b) No

5. Have you ever been hospitalized in the last three years? a) Yes b) No

6. If yes than, what was the reason for you to get hospitalized and what was the total expense that you had to incur for your hospitalization?

7. Are you addicted to any of the following? a) Alcohol b) Cigarettes c) Tobacco d) Narcotics e) Steroid 8. Is there any history of genetic illness in your family? a) Yes b) No

9. If yes, do you have that same illness? __________________________________