Are You Feeling Well Survey
Help us understand your current health and well-being by completing this short survey.
Full Name
First Name
Last Name
How are you feeling today?
*
Very well
Somewhat well
Neutral
Somewhat unwell
Very unwell
Please rate the following aspects of your current health:
*
Rows
Not at all
A little
Moderately
Quite a bit
Extremely
Physical energy
1
2
3
4
5
Mood
6
7
8
9
10
Sleep quality
11
12
13
14
15
Appetite
16
17
18
19
20
Stress level
21
22
23
24
25
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Fever
Cough
Fatigue
Headache
Sore throat
Muscle aches
Upset stomach
Shortness of breath
None of the above
Other
How would you rate your overall mood in the past week?
*
1
2
3
4
5
Have you noticed any recent changes in your health or well-being?
*
Yes
No
If yes, please describe the changes you have noticed.
How many hours of sleep do you typically get per night?
*
Please Select
Less than 5 hours
5-6 hours
6-7 hours
7-8 hours
More than 8 hours
Have you been in contact with anyone who is currently unwell in the past 7 days?
*
Yes
No
Not sure
Is there anything else you would like to share about your current health or well-being?
Submit Survey
Should be Empty: