Health and Wellbeing Questionnaire Template

1. How would you rate your overall health?

The answer should be a single choice:

1. Excellent
2. Good
3. Fair
4. Poor

2. Have you experienced any of the following health issues in the last six months? (Select all that apply)

The answer should be a multiple choice:

1. Headaches
2. Digestive issues (e.g. bloating, constipation, diarrhea)
3. Respiratory issues (e.g. coughing, wheezing, shortness of breath)
4. Skin issues (e.g. rash, hives, itching)
5. None of the above

3. How many hours of sleep do you typically get per night?

The answer should be a single choice:

1. Less than 5 hours
2. 5-6 hours
3. 6-7 hours
4. 7-8 hours
5. More than 8 hours

4. How many servings of fruits and vegetables do you typically consume per day?

The answer should be a single choice:

1. None
2. 1-2 servings
3. 3-4 servings
4. 5 or more servings

5. How often do you engage in physical activity?

The answer should be a single choice:

1. Never
2. Rarely (less than once a week)
3. Occasionally (1-2 times per week)
4. Regularly (3-4 times per week)
5. Daily

6. Do you have any dietary restrictions or preferences? (Select all that apply)

The answer should be a single choice:

1. Vegetarian
2. Vegan
3. Gluten-free
4. Dairy-free
5. None of the above

7. How would you rate your current level of stress?

The answer should be a single choice:

1. Very low
2. Low
3. Moderate
4. High
5. Very high

8. Have you experienced any of the following mental health issues in the last six months? (Select all that apply)

The answer should be a multiple choice:

1. Anxiety
2. Depression
3. Panic attacks
4. Insomnia
5. None of the above

9. How do you typically cope with stress?

The answer should be a single choice:

1. Exercise
2. Meditation or mindfulness
3. Talking to a friend or family member
4. Engaging in a hobby or creative activity

10. How would you rate the quality of your social support network?

The answer should be a single choice:

1. Excellent
2. Good
3. Fair
4. Poor

11. Do you feel that you have someone to turn to for emotional support when you need it?

The answer should be a single choice:

1. Yes
2. No

12. How satisfied are you with your current relationships (e.g. romantic, family, friendships)?

The answer should be a single choice:

1. Very satisfied
2. Satisfied
3. Neutral
4. Dissatisfied
5. Very dissatisfied