Healthcare Assessment Survey Template

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

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.

22 Questions

24Screens

3 mins to complete

List of Healthcare Assessment Survey Template Questions

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

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

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