Introducing User Segmentation — Deliver surveys and feedback forms with precise targeting using powerful User Segments. Learn more ➝

Get it For Free
×
Request a Demo

Book a Demo with Zonka Feedback

close-icon

Get Started for Free

Enter primary contact's full name
Enter primary contact's email address
Choose a password (at least 6 characters, no spaces, case-sensitive)
  • Your account is being created in the
By proceeding, you agree to the Terms of Service and Privacy Policy.
Or, sign up with email

user-picsrating-star crowd-logo captera-logo Rated 4.8/5 stars

close-icon

Get Started for Free

Enter primary contact's full name
Enter primary contact's email address
Choose a password (at least 6 characters, no spaces, case-sensitive)
  • Your account is being created in the
By proceeding, you agree to the Terms of Service and Privacy Policy.
Or, sign up with email

user-picsrating-star crowd-logo captera-logo Rated 4.8/5 stars

Healthcare Assessment Survey Template

Improve healthcare services using crucial patient insights to make informed decisions using this customizable Healthcare Assessment Survey Template.

  • Try 7 days for Free
  • Lightening fast setup
This survey covers various aspects of healthcare, including health status, lifestyle, healthcare services, and health insurance. By gathering patient insights, healthcare organizations can identify areas for improvement and enhance the quality of care they provide to patients.

Healthcare Assessment Survey Template Questions

The following questions are included in this Healthcare Assessment Survey Template.

  1. 1. How old are you?
  2. 2. What is your gender?
  3. 3. What is your ethnic background?
  4. 4. What is your employment status?
  5. 5. How would you rate your overall physical health?
  6. 6. How would you rate your overall mental/emotional health?
  7. 7. How would you rate your stress levels?
  8. 8. Do you have any chronic health conditions?
  9. 9. Please specify your chronic health conditions.
  10. 10. Do you have any hereditary conditions/diseases?
  11. 11. Please specify your hereditary conditions/diseases
  12. 12. Do you smoke or use tobacco products?
  13. 13. How often do you consume alcohol?
  14. 14. How would you rate your level of physical activity?
  15. 15. How many hours of sleep do you typically get per night?
  16. 16. Do you have any allergies
  17. 17. How often do you visit your primary care physician?
  18. 18. Have you ever been admitted to the hospital?
  19. 19. Please specify your reason for hospitalization
  20. 20. Do you have health insurance?
  21. 21. If you do not have health insurance, why not?
  22. 22. Please share any additional comments or concerns regarding your health

Healthcare Assessment Survey Template FAQ

Create and send this Healthcare Assessment Survey Template

Get Started