Q01
Message
All templatesHealthcare & Clinical
Personal Health Status & Wellbeing Evaluation
A whole-person health check-in covering self-rated health, energy, sleep, stress, symptom severity, and existing conditions — for clinics, employers, or wellness programs tracking how people are really doing. An AI follow-up interview digs into whatever symptom or condition the respondent flagged as most severe, uncovering impact and what they've already tried before their next visit.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
Q02
Multiple ChoiceRequired
Overall, how would you rate your health right now?
- Excellent
- Very good
- Good
- Fair
- Poor
Q03
Opinion ScaleRequired
In the last 30 days, how would you rate your typical energy level?
Scale: 1 – 7
Min:Constantly exhaustedMax:Full of energy
Q04
MatrixRequired
In the last 30 days, how often has each of the following been true for you?
4 rows × 5 columns
- I got 7+ hours of restful sleep
- I was physically active for at least 20 minutes
- I ate balanced meals with vegetables or fruit
- I felt able to manage day-to-day stress
Columns: Never · Rarely · Sometimes · Often · Always
Q05
Slider MatrixRequired
Right now, how severe is each of the following for you?
4 rows, one slider each
- Physical pain or discomfort
- Anxiety or worry
- Low mood or sadness
- Sleep difficulties
Slider 0–10Min:None at allMax:Severe
Q06
Multiple Choice
Do you currently have any of the following diagnosed health conditions?
- High blood pressure
- Diabetes
- Heart disease
- Asthma or a lung condition
- Anxiety or depression
- Arthritis or a joint condition
Q07
Rating ScaleRequired
How satisfied are you with your current overall health?
Range: 1 – 5
Min:Not at all satisfiedMax:Extremely satisfied
Q08
AI Interview
Identify whichever symptom or condition the respondent rated as most severe or flagged in their health history, and probe it in depth: how long it's been going on, how it affects daily life or work, what (if anything) they've already tried, and whether it's getting better, worse, or staying the same. If nothing stood out as severe, ask what one change would most improve their day-to-day health and why they haven't made it yet.
Q09
Multiple Choice
Which of these make it hardest for you to maintain healthy habits?
- Lack of time
- Cost
- Lack of motivation
- Pain or physical limitation
- Lack of support from others
- Stress or mental health
- Limited access to healthy food or exercise options
Q10
Long Text
Is there anything else about your health you'd like your care team to know before your next visit?
Q11
Dropdown
What is your age range? (Optional)
- Under 18
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65-74
- 75+
- Prefer not to say
Q12
Multiple Choice
What is your gender? (Optional)
- Woman
- Man
- Non-binary
- Prefer not to say
Q13
Message
Thank you for sharing this with us. Your responses will be reviewed alongside your health record to help personalize your care and flag anything that needs follow-up.
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 full whole-person snapshot in one flow — self-rated health, energy, sleep/stress frequency (matrix), and a slider matrix for symptom severity — not just a single satisfaction score.
- The AI follow-up interview automatically identifies whichever symptom or condition the respondent flagged as most severe and probes for impact and what they've already tried, something a static form template can't do.
- Captures practical context (barriers to healthy habits, open-ended notes for the care team, optional age/gender) so clinics or wellness programs get both structured data and narrative detail before a visit.
- Every response can be reviewed alongside auto-generated reports, with transparent prompts showing exactly how the AI follow-up was framed — no black-box scoring.
Jotform
Health Evaluation Form TemplateA ready-to-use, fielding-ready form template for general health evaluations, built on Jotform's drag-and-drop form builder. It's a solid starting point for collecting standard health intake fields but is a static questionnaire rather than an interactive interview. Customization is easy, but any follow-up on flagged symptoms would need to be manually scripted with conditional logic.
What it does well
- Familiar, easy-to-customize drag-and-drop form builder
- Fielding-ready template that can be deployed quickly
- Part of a broader ecosystem (integrations, e-signatures, file uploads) useful for clinical intake
Where it falls short
- No adaptive AI follow-up — any deeper probing requires manually built conditional logic, not a real interview
- No automated per-response quality scoring or auto-generated respondent reports
- No transparent prompt methodology since there's no AI interviewing layer at all
Typeform
Health Evaluation Form TemplateA conversational, one-question-at-a-time health evaluation template designed for a pleasant respondent experience. It's fielding-ready and benefits from Typeform's polished UI and branching logic, but it remains a fixed question set rather than a true adaptive interview. There's no mechanism to dynamically dig into whichever symptom a respondent rates as most severe.
What it does well
- Clean, conversational UI that tends to improve completion rates
- Built-in logic jumps for basic personalization between questions
- Fielding-ready template usable out of the box
Where it falls short
- No AI-driven follow-up interview — logic jumps are pre-set branches, not adaptive probing based on response content
- No automated quality scoring of individual responses
- No voice AI interview option or auto-generated clinical-style reports
Frequently asked questions
What questions are in the “Personal Health Status & Wellbeing Evaluation” template?
The template includes 13 ready-to-use questions, starting with: “Thanks for taking a few minutes for this health check-in. Your responses are completely confidential and anonymized. The…” · “Overall, how would you rate your health right now?” · “In the last 30 days, how would you rate your typical energy level?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 13 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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