Health Assessment Questionnaire Template

1. What is your age?

The answer should be a single choice:

1. Under 18
2. 18-24
3. 25-34
4. 35-44
5. 45-54
6. 55-64
7. 65 or over

2. What is your gender?

The answer should be a single choice:

1. Male
2. Female

3. What is your height in feet and inches?

The answer should be a single choice:

1. Less than 5 ft
2. 5 ft - 5 ft 5 in
3. 5 ft 6 in - 5 ft 11 in
4. 6 ft or taller

4. What is your weight in pounds?

The answer should be a single choice:

1. Under 100 lbs
2. 100-149 lbs
3. 150-199 lbs
4. 200-249 lbs
5. Over 250 lbs

5. How many hours of sleep do you get on average per night?

The answer should be a single choice:

1. Less than 6 hours
2. 6-7 hours
3. 8-9 hours
4. 10 or more hours

6. On average, how many days per week do you engage in moderate physical activity (e.g., brisk walking, cycling, swimming) for at least 30 minutes?

The answer should be a single choice:

1. None
2. 1-2 days
3. 3-4 days
4. 5 or more days

7. On average, how many servings of fruits and vegetables do you consume each day?

The answer should be a single choice:

1. Less than 1 serving
2. 1-2 servings
3. 3-4 servings
4. 5 or more servings

8. On average, how many alcoholic beverages do you consume per week?

The answer should be a single choice:

1. None
2. 1-2 drinks
3. 3-4 drinks
4. 5 or more drinks

9. Have you ever been diagnosed with any of the following conditions? (select all that apply)

The answer should be a multiple choice:

1. High blood pressure
2. Diabetes
3. High cholesterol
4. Heart disease
5. Stroke
6. Cancer
7. Asthma
8. Chronic obstructive pulmonary disease (COPD)
9. None of the above

10. Are you currently taking any prescription medications?

The answer should be a single choice:

1. Yes
2. No

11. Do you have any allergies?

The answer should be a single choice:

1. Yes
2. No

12. Have you had any surgeries in the past?

The answer should be a single choice:

1. Yes
2. No

13. In the past month, have you felt sad or hopeless for more than two weeks in a row?

The answer should be a single choice:

1. Yes
2. No

14. In the past month, have you felt anxious or worried for more than two weeks in a row?

The answer should be a single choice:

1. Yes
2. No

15. In the past month, have you experienced any sleep disturbances (e.g., trouble falling or staying asleep, nightmares)?

The answer should be a single choice:

1. Yes
2. No

16. In the past month, have you experienced any significant changes in your appetite or weight?

The answer should be a single choice:

1. Yes
2. No