Free Health Assessment Survey Template
Health Assessment Survey
Please take a few minutes to complete this health assessment survey.
Date
Personal Information
Name
Age
Gender
-
Male
-
Female
Phone Number
Health History
1. Do you have any existing medical conditions?
If yes, please specify:
2. Are you currently taking any medications?
If yes, please list:
3. Have you had any surgeries or hospitalizations in the past?
If yes, please describe:
Lifestyle Questions
4. How often do you exercise?
-
Daily
-
Several times a week
-
Once a week
-
Rarely
-
Never
5. How would you describe your diet?
-
Healthy and balanced
-
Mostly healthy
-
Average
-
Unhealthy
6. How many hours of sleep do you typically get each night?
-
Less than 5
-
5-6
-
7-8
-
More than 8
Additional Information
7. Do you have any specific health concerns you would like to address?
If yes, please specify:
8. Is there anything else you would like us to know about your health?
If yes, please specify:
9. On a scale of 1 to 10, how would you rate your overall stress level?
10. Do you have access to regular healthcare services?
Please check the box below to proceed
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