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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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Personal Health & Wellness Check-In Survey
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.
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Default theme. Colors and fonts are yours to change.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
11 questions · ~7 min
Q01
Opinion ScaleRequired
Overall, how would you rate your physical health right now?
Scale: 0 – 10
Min:PoorMax:Excellent
Q02
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
Q03
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
Q04
NumberRequired
On an average night over the past week, about how many hours did you sleep?
Q05
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
Q06
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
Q07
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
Q08
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.
Q09
Long Text
Is there anything else about your health or wellbeing you'd like to share?
Q10
Multiple Choice
Which age range do you fall into?
- Under 18
- 18–29
- 30–44
- 45–59
- 60–74
- 75+
- Prefer not to say
Q11
Multiple Choice
What is your gender?
- Female
- Male
- Non-binary
- Self-describe
- Prefer not to say
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 TemplateThis 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 templateThis 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
Frequently asked questions
What questions are in the “Personal Health & Wellness Check-In Survey” template?
The template includes 11 ready-to-use questions, starting with: “Overall, how would you rate your physical health right now?” · “Thinking about the past 2 weeks, how would you rate each of the following?” · “In the last 30 days, on how many days did you get at least 7 minutes of physical activity?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 11 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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