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Healthcare & Clinical

Environmental Health Concerns & Community Impact Survey

Captures how environmental conditions like air quality, extreme heat, and pollution are affecting people's health and daily choices, for public health teams and clinicians planning outreach. An AI follow-up interview digs into the respondent's most pressing environmental health concern to surface real symptoms, triggers, and what would actually help.

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Sample questions

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

14 questions · ~7 min
Q01
Message

Thanks for taking a few minutes to share how environmental conditions in your area affect your health. Your responses are completely confidential and anonymized. There are no wrong answers — this takes about 8 minutes and helps shape local health guidance.

Q02
Multiple ChoiceRequired

Which environmental issues are you most concerned about when it comes to your own health or your family's?

  • Air quality / pollution
  • Extreme heat
  • Water quality
  • Wildfire smoke
  • Flooding or extreme weather
  • Pesticides or chemical exposure
  • Mold or indoor air quality
  • Climate change generally
Q03
Opinion ScaleRequired

Overall, how concerned are you that environmental conditions where you live could harm your health?

Scale: 0 – 10
Min:Not at all concernedMax:Extremely concerned
Q04
MatrixRequired

In the last 3 months, how often have you experienced the following?

5 rows × 5 columns
  • Allergy or sinus symptoms you linked to outdoor air
  • Breathing difficulty or coughing on high-pollution or smoky days
  • Feeling unwell from heat (dizziness, fatigue, heat exhaustion)
  • Anxiety or stress about climate or environmental news
  • Skipping outdoor activity due to air or weather conditions
Columns: Never · Rarely · Sometimes · Often · Almost always
Q05
Multiple Choice

In the last 30 days, which of these have you done to protect your health from environmental conditions?

  • Checked an air quality or pollen index before going outside
  • Stayed indoors on a high-pollution or extreme-heat day
  • Worn a mask outdoors for air quality reasons
  • Used an air purifier or filter at home
  • Avoided tap water or used a filter/bottled water
  • Rescheduled outdoor exercise due to conditions
  • None of these
Q06
RankingRequired

Rank these environmental health risks by how urgently you think your local health department should address them, most urgent first.

  1. Air pollution
  2. Extreme heat
  3. Water contamination
  4. Wildfire smoke
  5. Chemical or pesticide exposure
  6. Mental health impacts of climate anxiety
Drag to rank
Q07
Best–Worst Trade-off (MaxDiff)Required

For each set, choose the intervention that would most and least improve your household's environmental health.

  • Free air quality monitors for homes
  • Cooling centers during heat waves
  • Clearer public alerts about pollution or smoke days
  • Free water quality testing
  • Subsidized air filters or purifiers
  • More neighborhood green space and tree cover
  • Health provider guidance on environmental risks
  • Public transit incentives to reduce emissions
Pick best & worst per setBest:Would help mostWorst:Would help least
Q08
Rating Scale

How well do healthcare providers you've seen address environmental factors as part of your health, if at all?

Range: 1 – 5
Min:Not addressed at allMax:Addressed very well
Q09
Opinion ScaleRequired

How much do you trust local health authorities to give you accurate, timely information about environmental health risks?

Scale: 1 – 7
Min:No trust at allMax:Complete trust
Q10
AI Interview

Focus on the environmental health issue the respondent rated as most concerning or ranked highest. Ask them to describe a specific recent moment when it affected their health, mood, or daily plans, what symptoms or reactions they noticed, and what (if anything) would make them feel meaningfully safer. If they say they're not concerned about any environmental issue, probe why — indifference, lack of awareness, or genuine low local risk.

Q11
Long Text

Is there anything else about environmental conditions and your health that you wish someone would ask or act on?

Q12
Multiple Choice

Which age range are you in?

  • Under 18
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65+
  • Prefer not to say
Q13
Short Text

What ZIP code or neighborhood do you primarily live in? (Prefer not to say is fine.)

Q14
Message

Thank you for sharing your experience! Your answers feed directly into a report that helps health teams prioritize environmental health outreach and resources in your community.

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

  • Includes a dedicated AI follow-up interview that focuses on whichever environmental health issue the respondent rated as most concerning, digging into real symptoms, triggers, and what would help — not just a fixed question list
  • Combines quantitative measures (opinion scales, a matrix of symptom frequency, ranking, and MaxDiff on interventions) with open-ended probing, giving public health teams both prevalence data and qualitative depth
  • Asks respondents to rate how well healthcare providers address environmental factors and how much they trust local health authorities — designed specifically for outreach and clinical planning, not general awareness
  • Ends with an auto-generated report pipeline, so responses (including the AI interview transcript) feed directly into a usable summary for public health teams

Jotform

Environmental Issues Survey Form Template

A ready-to-use static form template covering general environmental issue awareness, built on Jotform's drag-and-drop form builder. It's fielding-ready but generic — not tailored to health outreach or clinical planning use cases. No mention of adaptive questioning or interview-style follow-up.

What it does well

  • Fielding-ready template with Jotform's established drag-and-drop customization
  • Likely integrates with Jotform's broader form ecosystem (logic, integrations, file uploads)

Where it falls short

  • Static question set with no adaptive AI follow-up to probe individual concerns
  • No mention of automated per-response quality scoring or transparent prompt methodology
  • Not specifically designed for health outreach teams or clinician use

SurveyMonkey

Environmental Survey: Questions & Template

SurveyMonkey offers a template plus guidance on environmental survey questions, geared toward general environmental attitude research rather than health-specific outreach. It's a solid static starting point but reads partly as a question-bank/guide alongside the template. No adaptive or voice interview capability is indicated.

What it does well

  • Backed by SurveyMonkey's mature survey logic and reporting dashboards
  • Includes question guidance, useful for teams building their own instrument from scratch

Where it falls short

  • No adaptive AI interview to follow up on a respondent's specific top concern
  • No optional voice AI interview or guided screen-share tasks
  • No transparent prompt methodology or automated quality scoring per response

SurveySparrow

Environmental Awareness Survey Template

A conversational-style template focused on general environmental awareness rather than personal health impact or clinical outreach. SurveySparrow's chat-like UI gives a friendlier feel than a plain form, but the flow is still pre-scripted rather than truly adaptive. Good for community sentiment, less suited to symptom/trigger discovery.

What it does well

  • Conversational, chat-style question flow that feels more engaging than a plain form
  • Fielding-ready template aimed at community-level environmental awareness

Where it falls short

  • Conversational UI is scripted, not adaptive — no AI-generated follow-up probing based on individual answers
  • No voice AI interview option or guided task/screen-share capability
  • No automated quality scoring or transparent AI prompt disclosure

QuestionPro

Environmental survey | Survey questions on environmental pollution

QuestionPro's page combines a template with example questions on environmental pollution, functioning partly as a question-bank/guide rather than a single ready-to-field instrument. It targets general pollution awareness rather than personal health symptoms or clinical outreach planning. Standard static survey logic applies, no AI-driven interviewing.

What it does well

  • Broad library of pollution-related sample questions researchers can pull from
  • Backed by QuestionPro's established survey logic, panel, and analytics tools

Where it falls short

  • Static question bank/template with no adaptive AI follow-up interview
  • No option for voice AI interviews or guided screen-share tasks
  • No automated per-response quality scoring or published prompt transparency

Frequently asked questions

What questions are in the “Environmental Health Concerns & Community Impact Survey” template?

The template includes 14 ready-to-use questions, starting with: “Thanks for taking a few minutes to share how environmental conditions in your area affect your health. Your responses ar…” · “Which environmental issues are you most concerned about when it comes to your own health or your family's?” · “Overall, how concerned are you that environmental conditions where you live could harm your health?”. The full set is previewed above, and every question is editable.

How long does this survey take to complete?

Respondents typically finish the 14 questions in about 7 minutes.

Can I customize this template?

Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.

Is this template free to use?

Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.

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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