Measure What Matters for Whole-Person Health
Wellness Assessment Form
Assess physical health, mental wellbeing, nutrition, and lifestyle in one comprehensive evaluation—data that drives personalized wellness programs.
About This Template
Most wellness programs fail because they treat everyone the same. Generic advice like "eat better and exercise more" doesn't resonate when you don't know someone's starting point. Employees fake their way through corporate wellness screenings. Health coaches waste first sessions gathering basic information. Without baseline data, you can't measure progress or demonstrate ROI on wellness investments.
This template captures holistic wellness data across physical health (energy, sleep, exercise), nutrition (meals, hydration, dietary preferences), mental wellbeing (stress, mood, anxiety), and lifestyle factors (smoking, alcohol, screen time). Scale fields capture subjective ratings. Goal-setting sections identify what participants actually want to improve. Results create personalized starting points for any wellness program.
Health coaches start sessions with complete participant profiles. Corporate wellness programs segment employees into appropriate interventions. Track progress over time with repeat assessments—show 25% stress reduction after 3 months. Demonstrate wellness program ROI with measurable improvements. Participants feel heard because recommendations match their actual goals.
Key Features
- Physical health evaluation
- Mental wellness check
- Nutrition assessment
- Goal setting
Use Cases
Corporate Wellness Programs
Your company's wellness program offers gym subsidies, nutrition counseling, and stress management resources—but only 15% of employees participate. Without understanding individual needs, you can't match employees to relevant programs. Leadership questions the ROI of wellness benefits.
Pain point: One-size-fits-all wellness programs have low engagement. Can't demonstrate ROI without baseline and follow-up data. No way to segment employees into appropriate interventions.
Health Coaching Intake
Your health coaching practice spends first sessions gathering basic information—sleep habits, nutrition, stress levels, fitness routines. By the time you understand the client, the session is over. Clients feel they're paying for intake, not coaching.
Pain point: First coaching sessions spent on information gathering instead of coaching. No standardized baseline to measure progress. Coaches develop different intake habits, creating inconsistent client experiences.
Employee Assistance Program
Your EAP offers mental health resources, but employees don't know what's available or whether it applies to them. Wellness assessment identifies employees who might benefit from specific resources—high stress indicates EAP counseling, poor sleep suggests sleep programs.
Pain point: EAP resources underutilized because employees don't self-identify. HR can't proactively offer resources without knowing employee needs. Mental health issues go unaddressed until crisis.
Wellness Retreat Pre-Assessment
Your wellness retreat offers yoga, meditation, fitness classes, and spa services. Guests arrive without staff knowing their goals or limitations. A guest with chronic pain gets placed in an intense yoga class. A guest seeking stress relief ends up in a fitness boot camp.
Pain point: Guests mismatched to activities based on availability, not needs. Staff learn about limitations during activities, causing awkward adjustments. Personalized programming requires lengthy in-person intake.
Form Fields (32)
Basic Information
Full Name
Email Address
your@email.comDate of Birth
Gender
Select gender...Height (inches)
Weight (lbs)
Physical Health
Rate your overall physical health
Rate your typical energy level
How often do you exercise?
Select how often do you exercise?...Types of exercise you do
Average hours of sleep per night
Select average hours of sleep per night...Rate your sleep quality
Nutrition
How many meals do you typically eat per day?
Select how many meals do you typically eat per day?...Daily water intake
Select daily water intake...Servings of fruits/vegetables per day
Select servings of fruits/vegetables per day...Dietary restrictions or preferences
Mental & Emotional Wellbeing
Rate your typical stress level
Rate your overall mood most days
How often do you experience anxiety?
Select how often do you experience anxiety?...How do you typically manage stress?
Lifestyle Factors
Tobacco use
Select tobacco use...Alcohol consumption
Select alcohol consumption...Daily screen time (non-work)
Select daily screen time (non-work)...Health Goals
What are your health goals?
Describe your specific health goals
How motivated are you to make changes?
Select how motivated are you to make changes?...Customization Tips
Add Biometric Data Fields
Include fields for blood pressure, resting heart rate, and body composition if participants have access to these measurements. Creates more complete health profile.
Enable Progress Tracking
Create a repeat assessment workflow where participants complete the same form quarterly. Compare results over time to show wellness program impact.
Add Mental Health Screening
Include validated screening tools (PHQ-9 for depression, GAD-7 for anxiety) to identify participants who might benefit from professional support.
Segment by Risk Level
Use conditional logic to calculate risk scores based on responses. High-risk participants (sedentary + high stress + poor sleep) get flagged for priority intervention.
Add Wearable Device Integration
If participants use fitness trackers, add fields to capture device data (average daily steps, sleep data) for more objective measurements.
Suggested Workflows
Generate Custom Wellness Plan
Trigger: On form submissionBased on assessment responses, automatically generate personalized recommendations: high stress triggers meditation app suggestion, poor sleep triggers sleep hygiene tips, sedentary lifestyle triggers fitness program invitation.
Flag High-Risk Participants
Trigger: On submission where risk score exceeds thresholdWhen assessment reveals concerning combinations (very high stress + poor sleep + low mood), automatically notify wellness coordinator for personal outreach. Includes EAP resources for immediate support.
Match to Appropriate Coach
Trigger: On form submissionBased on primary goals (weight loss, stress management, fitness), automatically assign participant to appropriate health coach specialty. Coach receives participant profile before first session.
Schedule Follow-up Assessment
Trigger: Scheduled - 90 days after submissionAfter 90 days, automatically send follow-up assessment to measure progress. Compare results to baseline and generate progress report showing improvements.
Developer Notes
Schema Highlights
Scale fields (1-10) stored as integers enable easy comparison and trending over time
Health goals stored as multi-select array allows segmentation and program matching
Height/weight fields enable BMI calculation if needed (consider privacy implications)
Integration Hints
Wellness platform API integration (Virgin Pulse, Limeade) for enterprise wellness programs
Wearable device APIs (Fitbit, Apple Health) to supplement self-reported data with objective metrics
Calendar integration to auto-schedule follow-up assessments and coaching sessions
MongoDB Considerations
Index on {healthGoals: 1} for segmentation queries (all participants wanting weight loss)
Index on {stressLevel: 1, moodRating: 1} for mental health risk identification
Store assessment date for time-series comparisons across multiple assessments
Consider aggregation pipeline for calculating risk scores from multiple fields
Tags
Get Started
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Complexity
Form Type
Est. Completion
~12 min
Total Fields
32
Category
Healthcare & Wellness