A medical intake survey is done in order to assess the health conditions of a person before admitting him/her in the hospital/clinic and starting the treatment process. The survey is usually conducted by the concerned medical authorities of a private hospital or a public medical institute. The people who take the survey are in general or specific needs of medical care. It is implied that the persons taking the survey would answer the questions sincerely.

Sample Medical Intake Survey:

1. Do you suffer from blood pressure problems?

a. Yes

b. No

c. Sometimes

2. Have you ever felt any difficulty while breathing?

a. Yes

b. No

c. Sometimes

3. Have you ever been admitted to a hospital?

a. Yes

b. No

4. Do you feel that you have incurred a contagious disease?

a. Yes

b. No

c. Don’t know

5. Are you able to move your limbs properly?

a. Yes, quite comfortably

b. Yes, with little uneasiness

c. No, feeling uneasiness

6. Are you currently going on any kind of medication?

a. Yes( Provide details)

b. No

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