Health and Wellbeing Questionnaire Template

Struggling to find the right questions? Pressed for time? Use this health and wellbeing survey template to get started quickly.

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Number of questions

25

Time to complete

15 minutes

Customisable?

Yes

Health and wellbeing questions in this example

To get you started quickly, this questionnaire template comes pre-populated with example questions you may wish to ask your survey participants. The example is for a survey of patients aged 65+, and can be adapted to the demographic being surveyed.

The provided questions can be quickly and easily amended, and questions added or removed, to meet your exact needs. Other question types are available, and survey templates can be styled to reflect the identity of your clinic, hospital or agency.

In regards to treating age related health problems, how would you rate the hospitals in your area?

Multiple choice question with single-select answer.

Which of the following best describes your overall health?

Multiple choice question with single-select answer.

Is there someone within your family or friends who can fulfil your needs when you wish to talk or go on outings?

Multiple choice question with single-select answer.

How often do close friends and relatives visit you?

Multiple choice question with single-select answer.

Which of the following best describes your ability to perform everyday tasks?

Multiple choice question with single-select answer.

How easily can you travel long distances?

Multiple choice question with single-select answer.

Are you able to complete your housework?

Multiple choice question with single-select answer.

Are you able to go shopping?

Multiple choice question with single-select answer.

Are you able to prepare your own meals?

Multiple choice question with single-select answer.

Are you able to do your laundry?

Multiple choice question with single-select answer.

Can you handle your finances?

Multiple choice question with single-select answer.

Do you take care over your own appearance?

Multiple choice question with single-select answer.

Can you dress yourself?

Multiple choice question with single-select answer.

How many different types of medication have you taken over the last 24 hours?

Free-form answer box.

How many types of medication, if any, are prescribed by your GP?

Free-form answer box.

If you take medication, how do you take it?

Multiple choice question with single-select answer.

Do you or your partner experience any chronic pain?

Multiple choice question with single-select answer.

If you answered yes, then what sort of treatment is being received for the pain?

Free-form text box.

What is your age category?

Multiple choice question with single-select answer.

What is your gender?

Multiple choice question with single-select answer.

How many residents live in your household?

Free-form answer box.

What are your living arrangements?

Multiple choice question with single-select answer.

Do your rent or own your home?

Multiple choice question with single-select answer.

What is your employment status?

Multiple choice question with single-select answer.

What is your marital status?

Multiple choice question with single-select answer.

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