Personal Health Assessment Checklist Form
Evaluate your general health and wellness habits. This form is for personal self-assessment only and does not collect sensitive medical information.
Your Name
First Name
Last Name
How would you rate your overall health in the past week?
*
1
2
3
4
5
How many days per week do you engage in at least 30 minutes of physical activity?
*
Please Select
0 days
1-2 days
3-4 days
5-6 days
7 days
How would you describe your typical sleep quality?
*
Excellent
Good
Fair
Poor
How often do you feel stressed or anxious?
*
Rarely
Sometimes
Often
Almost always
How would you rate your typical daily nutrition?
*
1
2
3
4
5
In the past week, how many servings of fruits and vegetables did you eat per day on average?
*
Please Select
0-1 servings
2-3 servings
4-5 servings
6 or more servings
How often do you consume sugary drinks or snacks?
*
Rarely
Sometimes
Often
Daily
Please indicate your agreement with the following statements about your health habits.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel energetic during the day
1
2
3
4
5
I am satisfied with my current health habits
6
7
8
9
10
I make time for relaxation or leisure activities
11
12
13
14
15
Is there anything else about your personal health or habits you'd like to note?
Submit Assessment
Should be Empty: