Health Risk Screening Questionnaire
Lifestyle screening for wellness programmes: activity, smoking, sleep, and readiness to change.
4 questions · 1 page · about 1 minute to answer · fully editable after you start
Workplace and community wellness programmes start with an honest baseline. This screening covers the modifiable risks – activity, smoking, alcohol, sleep, and stress – and closes with the question that predicts programme success: which habit the person actually wants to change first.
Run it anonymously at the population level to target your programme budget, or identified (with consent) for personal coaching pathways. The readiness answer sorts participants into who needs information versus who needs support.
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Page 1
Your health habits
This questionnaire asks about your lifestyle and health habits. It gives a general picture of common health risks and is not a diagnosis. It takes about 1 minute. This form is not an emergency service. If you need urgent medical help, call your local emergency number.
Q1.How many days a week do you get 30+ minutes of moderate activity?*
- 0-1 days
- 2-3 days
- 4-5 days
- 6-7 days
Q2.Do you smoke or vape?*
- No, never
- No, I quit
- Occasionally
- Daily
Q3.In a typical week...
| Rarely | Some days | Most days | |
|---|---|---|---|
| I sleep 7+ hours a night | |||
| My stress feels manageable | |||
| I eat fruit and vegetables daily |
Q4.If you changed one habit this year, which would it be?
- Move more
- Eat better
- Sleep better
- Reduce smoking or alcohol
- Manage stress
- Other…
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