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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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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

13 questions · ~7 min
Q01
Message

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

Q02
Opinion ScaleRequired

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

Scale: 0 – 10
Min:PoorMax:Excellent
Q03
Slider MatrixRequired

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

4 rows, one slider each
  • Energy level
  • Stress level
  • Sleep quality
  • Overall mood
Slider 0–10Min:Very low / poorMax:Very high / great
Q04
Multiple ChoiceRequired

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
NumberRequired

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

Q06
Multiple ChoiceRequired

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
Multiple ChoiceRequired

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
Rating ScaleRequired

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

Range: 1 – 5
Min:Not confident at allMax:Very confident
Q09
AI Interview

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
Long Text

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

Q11
Multiple Choice

Which age range do you fall into?

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

What is your gender?

  • Female
  • Male
  • Non-binary
  • Self-describe
  • Prefer not to say
Q13
Message

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.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • 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.

What it does well

  • 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

Where it falls short

  • 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.

What it does well

  • 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

Where it falls short

  • 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

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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