Free Student Daily Wellness Assessment Form Template

Student Daily Wellness Assessment Form

Please fill out this form to assess your daily wellness and track your overall well-being.

Personal Information

Name

    Grade/Year

      Date

        Physical Wellness

        On a scale of 1 to 10, how would you rate your physical health today?

          Any physical discomfort or symptoms?

            • Headache

            • Fatigue

            • Soreness

            • Nauseous

            Emotional Wellness

            On a scale of 1 to 10, how would you rate your emotional state today?

              Any notable emotions you experienced today?

                • Joy

                • Sadness

                • Stress

                Mental Wellness

                On a scale of 1 to 10, how would you rate your mental clarity and focus today?

                  Any challenges with concentration or focus?

                    Social Wellness

                    Did you interact with others today?

                    If yes, how would you rate your social interaction?

                      Daily Reflection

                      Any positive experiences, challenges, or thoughts you'd like to share today?

                        Please check the box below to proceed

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