--- title: "Health questionnaire template: wellbeing and habits survey" description: "A 13-block health questionnaire template: consent, gender and date of birth, symptom frequency over a month, sleep and stress on 0–10 sliders, habits." url: https://askyo.ru/en/templates/health-survey lang: en last_modified: 2026-09-27 --- 1. [Home](https://askyo.ru/en) 2. [Survey templates](https://askyo.ru/en/templates) 3. [Research](https://askyo.ru/en/templates/category/research) 4. Health questionnaire Template # Health questionnaire A self-assessment of wellbeing: sleep, stress, habits. Built as a questionnaire for a clinic or a corporate health programme. - 13 blocks [Open the template in the builder ](https://app.askyo.ru/build)[More on this: Create a questionnaire](https://askyo.ru/en/questionnaire) Template ## Who it is for and when to run it This is a self-assessment, not a diagnosis. Corporate wellbeing programmes use it before a challenge starts, coaches and nutritionists at the first consultation, clinics as a pre-appointment screen. In every case the goal is the same: a picture of how someone feels before they talk to a specialist. Repeat it a month or two later with the same wording and you’ll see the change. Don’t edit the questions between waves. If you are a clinic and the answers will become part of a medical record, have your privacy lead or lawyer review the consent text. Health data carries stricter rules almost everywhere. Showcase ## What the template is made of Every block in the order it sits in the builder. Branching decides which of them a given person actually sees. 1. Self-assessment [Text block](https://askyo.ru/en/question-types/statement) The intro says answers are anonymous and not shared with third parties. Make sure that’s true for your process before you publish. 2. Consent to anonymous participation [Consent](https://askyo.ru/en/question-types/consent) Required consent to anonymous processing of health data. Don’t collect answers like these without it. 3. About you [Section break](https://askyo.ru/en/question-types/divider) The “About you” section break sets the demographics apart. 4. Your gender [Single choice](https://askyo.ru/en/question-types/single-choice) Gender, with an “Other / prefer not to say” option, so people can answer honestly or skip without abandoning the form. 5. Date of birth [Date](https://askyo.ru/en/question-types/date) Date of birth instead of age: you can build age bands later, and the value doesn’t go stale by the next wave. 6. How you feel [Section break](https://askyo.ru/en/question-types/divider) The “How you feel” section opens the main block. 7. Over the past month, how often did you… [Matrix](https://askyo.ru/en/question-types/matrix) A frequency [matrix](https://askyo.ru/en/question-types/matrix) for the past month: morning tiredness, lying awake over 30 minutes, skipped meals, exercise, walks. Five rows on one screen instead of five questions. 8. Sleep quality over the past week [Slider](https://askyo.ru/en/question-types/slider) Sleep quality over the past week on a 0–10 slider. A short period is remembered more accurately than “in general”. 9. Stress level [Slider](https://askyo.ru/en/question-types/slider) Stress level on the same slider, so the two are easy to compare for one person. 10. Habits [Section break](https://askyo.ru/en/question-types/divider) The “Habits” section opens the last block. 11. Which of these habits do you have? [Multiple choice](https://askyo.ru/en/question-types/multi-choice) Tick the habits that apply: smoking, exercise, diet, breathing practice, contrast showers. Ticking is more honest than “do you live healthily?”. 12. Do you take medication regularly? [Yes / No](https://askyo.ru/en/question-types/yes-no) Yes/no on regular medication, with no drug names. For a self-assessment the fact is enough, and you avoid collecting extra medical data. 13. What would you like to change about your lifestyle? [Long answer](https://askyo.ru/en/question-types/long-text) An open question on what they’d like to change. It bridges into the consultation or the programme. Template ## How to adapt the template 1. If the questionnaire isn’t anonymous, say a personal trainer’s client intake, rewrite the intro and consent and add name and contact fields. Never keep the word “anonymous” next to a phone field. 2. Swap the matrix rows for your programme: “Worked after 10 pm” for a workplace challenge, “Snacked on the go” for a nutritionist. 3. Replace the date of birth with an age band if you don’t need the exact date. Less data, less risk. 4. For a clinic, add a free-text question about current complaints and drop habits that don’t matter for the appointment. 5. Switch to one question per screen: on a phone a health form feels calmer that way. Template ## How to read the results Read the matrix row by row: the share of “Often” and “Every day” answers for each item. The row with the biggest share is your topic for the programme or the conversation. Compare sleep and stress for the same person, not just group averages. Poor sleep combined with high stress matters more than either number alone. In a repeat wave, compare the same people or the same group. If the group changed, shifting averages may just mean different participants. The questionnaire doesn’t say what is “normal”, and you shouldn’t invent thresholds. Health conclusions are for a qualified professional. Template ## Common mistakes - Promising anonymity while collecting an email “for your results”. People notice and answer more cautiously. - Adding diagnosis and medication-name questions you don’t need. Each one raises the bar for storing the data. - Treating answers as a medical assessment. It measures how people feel, not lab results. - Changing wording between waves and then comparing the numbers. Frequently asked questions ## Questions about the «Health questionnaire» template What should a health questionnaire include? Basic demographics, how often symptoms occurred over the past month, sleep quality and stress level, habits and whether the person takes regular medication, and a closing question on what they want to change. This template contains exactly that set, without diagnoses or drug names. Do I need consent for a health survey? Yes. Health information is sensitive personal data in most jurisdictions, so consent is the second block of the template and it’s required. The default wording covers anonymous statistics; a clinic should have its own consent text reviewed. Can a health questionnaire be anonymous? Anonymity comes from the questions you ask: the service doesn’t ask for a name by itself. With no contacts or identifying details, the form is anonymous. In a small group, gender plus date of birth can still identify someone, so use an age band instead. Template ## Similar templates - ### [UX interface research](https://askyo.ru/en/templates/ux-research) Cards, images and scales: for an in-depth product interview. - ### [Customer expectations](https://askyo.ru/en/templates/customer-expectations) What matters when choosing, and which criteria people compare on. - ### [In-depth market research](https://askyo.ru/en/templates/market-research-deep) Matrices, ranking, pairwise comparisons and budget allocation. ## Where to go next The whole job, not just the template: - [Create a questionnaire](https://askyo.ru/en/questionnaire) - [Category «Research»](https://askyo.ru/en/templates/category/research) - [All templates](https://askyo.ru/en/templates) - [Question types](https://askyo.ru/en/question-types) - [Pricing](https://askyo.ru/en/pricing) ## Do not start from an empty canvas Open the catalog, take the closest template and rewrite the questions for your job. Five minutes instead of an hour. [Open the template in the builder ](https://app.askyo.ru/build)[See pricing](https://askyo.ru/en/pricing)