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Healthcare & Clinical

Personal Health & Wellness Check-In Survey

A periodic self-assessment covering physical health, sleep, stress, activity levels, and emerging symptoms — used by clinics, employers, or wellness programs to spot concerns early. An AI follow-up interview digs into whatever symptom or concern the respondent flagged as most pressing, capturing duration, severity, and impact that a checkbox can't.

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設問の例

テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。

全13問・約7分
Q01
メッセージ

Hi! This quick check-in helps us understand how you're doing physically and mentally right now. Your responses are completely confidential and anonymized. There are no wrong answers — just be honest. It takes about 5 minutes.

Q02
オピニオンスケール必須

Overall, how would you rate your physical health right now?

スケール: 0 – 10
最小:Poor最大:Excellent
Q03
スライダーマトリクス必須

Thinking about the past 2 weeks, how would you rate each of the following?

4行（各行にスライダー1つ）
  • Energy level
  • Stress level
  • Sleep quality
  • Overall mood
スライダー 0〜10最小:Very low / poor最大:Very high / great
Q04
選択式必須

In the last 30 days, on how many days did you get at least 7 minutes of physical activity?

  • 0 days
  • 1–4 days
  • 5–9 days
  • 10–19 days
  • 20+ days
Q05
数値必須

On an average night over the past week, about how many hours did you sleep?

Q06
選択式必須

Which of the following have you noticed in the past 2 weeks?

  • Persistent fatigue
  • Trouble falling or staying asleep
  • Headaches
  • Digestive issues
  • Muscle or joint pain
  • Anxiety, worry, or low mood
  • Shortness of breath or chest discomfort
Q07
選択式必須

When did you last have a general check-up or physical exam with a doctor?

  • Within the last year
  • 1–2 years ago
  • More than 2 years ago
  • Never
  • Not sure
Q08
評価スケール必須

How confident do you feel in your ability to manage your current health needs day-to-day?

範囲: 1 – 5
最小:Not confident at all最大:Very confident
Q09
AIインタビュー

If the respondent flagged any symptom in the checklist question (fatigue, sleep trouble, headaches, digestive issues, pain, anxiety/mood, or breathing issues), probe that specific one first: how long it's been going on, how severe it feels day to day, whether it's getting better, worse, or staying the same, and whether it's affected work, sleep, or relationships. If they selected 'None of these', instead explore what's been going well and whether anything is building up that they haven't mentioned yet. If they haven't seen a doctor in over a year, gently ask what's kept them from scheduling one.

Q10
自由回答（長文）

Is there anything else about your health or wellbeing you'd like to share?

Q11
選択式

Which age range do you fall into?

  • Under 18
  • 18–29
  • 30–44
  • 45–59
  • 60–74
  • 75+
  • Prefer not to say
Q12
選択式

What is your gender?

  • Female
  • Male
  • Non-binary
  • Self-describe
  • Prefer not to say
Q13
メッセージ

Thank you for checking in! Your answers help identify patterns early and shape the support and resources offered to you. If you flagged anything urgent, please don't wait — reach out to a healthcare provider directly.

含まれる機能

  • AIによる深掘り

    自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。

  • 注意確認設問

    急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。

  • AIが作成する設問文

    文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。

  • 自動レポート

    回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。

他ツールとの比較

ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。

このテンプレートを選ぶ理由

  • Opens with a friendly chat message and closes with a thank-you message, framing the check-in as a conversation rather than a cold form
  • Covers physical health self-rating, a 2-week slider matrix across multiple wellness dimensions, activity days, sleep hours, a symptom checklist, and last-check-up timing in one structured flow
  • An AI follow-up interview automatically digs into whichever symptom or concern the respondent flags as most pressing, capturing duration, severity, and impact that a checkbox alone can't surface
  • Adds an open-ended long-text question, demographic breakdowns, and auto-generated reports so clinics, employers, or wellness programs can spot patterns and act early

Typeform

Student Mental Health Checkin Survey Template

This is a ready-to-field template built around Typeform's conversational, one-question-at-a-time interface, focused specifically on student mental health check-ins. It's a narrower periodic check-in than QuestionPunk's template, covering mental health only rather than physical health, sleep, activity, and stress together, and it targets students rather than a general clinic/employer/wellness-program population.

優れている点

  • Typeform's polished, mobile-friendly conversational UI is well suited to sensitive check-in topics
  • Purpose-built for a specific audience (students) and single domain (mental health), which can feel more tailored for that niche

物足りない点

  • Static question set with no adaptive AI follow-up to probe deeper into a flagged concern's duration, severity, or impact
  • No published methodology or transparent prompt logic since there are no AI-driven questions to document
  • Scope limited to mental health and students, missing physical health, sleep, activity levels, and general check-up tracking

QuestionPro

Contactless health check survey template

This template appears designed for entry-point/contactless symptom screening (e.g., before entering a workplace or facility) rather than an ongoing personal wellness self-assessment. It's a fielding-ready form, but its purpose is narrower and more transactional than a periodic physical, sleep, stress, and activity check-in.

優れている点

  • Backed by QuestionPro's enterprise survey platform with standard logic and distribution features
  • Suited to quick, repeatable screening use cases like facility or workplace entry checks

物足りない点

  • Static checklist format with no adaptive AI interview to explore whatever symptom a respondent flags in more depth
  • No automated per-response quality scoring or transparent AI prompt documentation, since it isn't AI-interview based
  • Narrower scope (contactless symptom screening) versus a broader periodic wellness check covering sleep, stress, and activity trends

よくあるご質問

「Personal Health & Wellness Check-In Survey」テンプレートにはどのような設問が含まれていますか？

すぐに使える設問が13問含まれており、最初の設問は次のとおりです：「Hi! This quick check-in helps us understand how you're doing physically and mentally right now. Your responses are compl…」・「Overall, how would you rate your physical health right now?」・「Thinking about the past 2 weeks, how would you rate each of the following?」。すべての設問は上でプレビューでき、自由に編集できます。

このアンケートの回答にはどのくらい時間がかかりますか？

回答者は通常、13問を約7分で回答し終えます。

テンプレートは編集できますか？

はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。

このテンプレートは無料で使えますか？

はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。

公開の準備はできましたか？

このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。

このテンプレートを使う無料で始める

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