Heat Sensitivity Assessment Form
Use this form to assess how you experience heat, what situations affect you most, and what support or guidance may be helpful. Keep responses general and do not include sensitive personal or medical details.
Assessment Details
Name
Email address
example@example.com
Age range
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Primary reason for taking this assessment
Heat Sensitivity Experience
Overall heat discomfort level
*
No discomfort
1
2
3
4
5
6
7
8
9
Extreme discomfort
10
1 is No discomfort, 10 is Extreme discomfort
How often do heat-related symptoms occur?
*
Occasionally
Frequently
Heat sensitivity in common situations
*
Rows
Not affected
Mild
Moderate
Severe
Not applicable
Warm weather
1
2
3
4
5
Indoor heat
6
7
8
9
10
Exercise
11
12
13
14
15
Direct sun
16
17
18
19
20
Poor ventilation
21
22
23
24
25
Triggers, Habits, and Support Needs
Common heat triggers or aggravating conditions
*
Direct sunlight
High humidity
Hot indoor spaces
Physical activity
Tight clothing
Stress
Dehydration
Other
Strategies you already use to stay comfortable
Preferred support
*
General comfort tips
Follow-up guidance
No additional support needed
Submit
Should be Empty: