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Wellness Evaluation Form

A wellness evaluation form is used to assess an individual's physical and mental well-being. The form can be used by healthcare professionals, employers, or individuals themselves. The purpose of a wellness evaluation form is to help identify areas of improvement for an individual's overall health and wellbeing. It can be used to set health goals, make lifestyle changes, or track progress over time.

Time to complete

2 minutes

Eligibility

Any individual who is into fitness and well being can fill this form.

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Questions for Wellness Evaluation Form

1.

Full Name

The answer should be a text input.
2.

Gender

The answer should be a single choice:
  1. Male
  2. Female
  3. Other
  4. Prefer not to say
3.

Age

The answer should be a single choice:
  1. Under 18
  2. 18-24 years old
  3. 25-34 years old
  4. 35-44 years old
  5. 45-54 years old
  6. Over 55
4.

Phone Number

The answer should be a phone number.
5.

Email Address

The answer should be an email input.
6.

How frequently do you exercise?

The answer should be a single choice:
  1. Never
  2. Rarely
  3. Sometimes
  4. Almost always
7.

How would you rate your diet?

The answer should be a single choice:
  1. Very unhealthy
  2. Unhealthy
  3. Moderately healthy
  4. Healthy
8.

How much water do you drink each day?

The answer should be a single choice:
  1. None
  2. A little bit
  3. Enough
  4. Too much
9.

How many hours of sleep do you get each night?

The answer should be a single choice:
  1. Almost none
  2. A few
  3. Enough
  4. Too much
10.

How much stress do you feel on a daily basis?

The answer should be a single choice:
  1. A lot
  2. Some
  3. A little
  4. Almost none
11.

How would you rate your overall health?

The answer should be a rating.
12.

How would you rate your energy levels?

The answer should be a rating.
13.

How often do you visit the doctor or a medical professional?

The answer should be a text input.
14.

Do you have any allergies or medical condition?

The answer should be a text input.

Similar Ideas

  • Personal Wellness Evaluation
  • Wellness Evaluation for Employees
  • Wellness Evaluation for Students
  • Wellness Evaluation for Athletes
  • Wellness Evaluation for Veterans.

Here are some FAQs and additional information
on
Wellness Evaluation Form

What is the Wellness Evaluation Form?

The Wellness Evaluation Form is a tool used by healthcare providers to assess an individual's overall health and wellness. The form includes questions about the individual's medical history, lifestyle, and current health status.

Who can use the Wellness Evaluation Form?

The Wellness Evaluation Form can be used by any healthcare provider, including doctors, nurses, and other medical professionals.

How can the Wellness Evaluation Form be used?

The Wellness Evaluation Form can be used to assess an individual's overall health and wellness, and to identify areas where improvements can be made. The form can also be used to track an individual's progress over time.

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