Wellness Assessment Form Template
Evaluate overall patient wellness with a comprehensive assessment covering physical health, mental wellness, nutrition, sleep, and lifestyle habits.
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What is a Wellness Assessment Form?
A wellness assessment form is a comprehensive health questionnaire that evaluates a person's overall well-being across multiple dimensions: physical health, mental health, exercise habits, nutrition, sleep quality, stress levels, and social support. It provides a holistic view of health beyond treating acute illness.
Wellness assessments help identify health risks, establish baseline wellness status, and set personalized health goals. They're used in preventive medicine, corporate wellness programs, health coaching, and wellness clinics to optimize long-term health outcomes.
Effective wellness assessments typically take 10-15 minutes and use a combination of questions, scales, and scoring to provide actionable insights. Results can be shared with health coaches or providers to guide personalized wellness interventions.
Key Features
Physical Health Assessment
Questions about exercise frequency, weight concerns, and physical fitness
Mental Health Screening
Assessment of stress levels, anxiety, depression, and emotional well-being
Sleep Quality Evaluation
Questions about sleep duration, quality, and sleep disorders
Nutrition & Diet Assessment
Evaluation of eating habits, dietary restrictions, and nutrition goals
Substance Use Screening
Assessment of alcohol, tobacco, and other substance use
Wellness Scoring
Automatic scoring and wellness score generation (optional Pro feature)
Why Use This Template?
Identify Health Risks
Spot physical and mental health risks before they become serious conditions
Set Personalized Goals
Assessment results inform individualized wellness plans and health goals
Preventive Intervention
Address lifestyle factors (exercise, nutrition, sleep) that prevent disease
Holistic Health View
Understand the whole person beyond single complaints or diagnoses
What's Included in This Template
How many days per week do you exercise?
selectAssesses physical activity level and cardio health
How would you rate your stress level?
selectIdentifies stress management needs and mental health support
How many hours of sleep do you typically get?
selectEvaluates sleep duration and identifies sleep disorders
Current weight & height
textCalculates BMI and identifies weight-related health concerns
How often do you experience anxiety?
selectScreens for anxiety disorders and mental health needs
Tobacco/Nicotine Use
selectIdentifies smoking cessation needs and cardiovascular risk
Alcohol consumption per week
selectScreens for problematic drinking and substance use issues
What are your top health goals?
textareaIdentifies patient priorities for coaching and intervention
Perfect For
Corporate Wellness Programs
Employee health screening and wellness initiative enrollment
Health Coaching
Initial assessment for personalized health coaching and behavior change
Preventive Medicine Clinics
Comprehensive health assessment for disease prevention and wellness
Fitness & Gym Memberships
Health screening and fitness goal assessment before training
Frequently Asked Questions
How should I score the wellness assessment?
Create a point system (e.g., exercise = 0-20 points, mental health = 0-20 points, sleep = 0-20 points). Total possible 100. Scores below 60 indicate multiple wellness concerns needing intervention. Use the results to guide coaching conversations and personalized health plans.
Should I include mental health screening?
Yes - mental health is crucial wellness component. Screen for depression (PHQ-2 or PHQ-9), anxiety, stress, and substance use. Be prepared to provide mental health resources or referrals if assessments indicate concerns. Train staff to respond supportively to mental health disclosures.
Can I use this for corporate wellness?
Yes - corporate wellness programs use comprehensive assessments to identify health risks, establish baselines, and track improvement. Ensure privacy compliance (HIPAA if applicable). Share results only with the employee and designated wellness vendors, never with employers.
How do I follow up on assessment results?
Schedule a follow-up conversation to discuss results and create an action plan. Offer referrals to health coaches, counselors, or specialists as needed. Re-assess every 3-6 months to track progress toward wellness goals.
Should I assess nutritional status?
Yes - include questions about eating habits, dietary patterns, and nutrition concerns. Ask about meals per day, fruit/vegetable intake, and special diets. Consider referral to registered dietitian for detailed nutrition assessment and counseling.
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