Skip to content
Askalot

← All Healthcare templates

Questionnaire template

Health Risk Factor Questionnaire

Screens adults for lifestyle, body-measure, medical-history, sleep and stress risk factors for chronic disease.

Preview

Healthcare · Patient. All Healthcare templates

Questions in this template

About You

  1. This questionnaire looks at everyday habits and health factors that can affect your long-term health. Your answers are confidential and help identify where support could make a difference.

  2. How old are you?

    A number from 18 to 110

  3. What sex were you assigned at birth?

    Choose one:

    • Female
    • Male
    • Prefer not to say

Lifestyle

  1. Which best describes your smoking?

    Choose one:

    • I have never smoked
    • I used to smoke
    • I smoke occasionally
    • I smoke every day

  2. About how many cigarettes do you smoke a day?

    Condition: Asked of daily smokers

    A number from 1 to 100

  3. In the past 7 days, on how many days did you do at least 30 minutes of moderate physical activity, such as brisk walking or cycling?

    A number from 0 to 7

  4. On a typical day, how many portions of fruit and vegetables do you eat?

    A number from 0 to 20

  5. How often do you drink alcohol?

    Choose one:

    • Never
    • Monthly or less
    • 2-4 times a month
    • 2-3 times a week
    • 4 or more times a week

Body Measurements

  1. What is your height?

    A number from 100 to 250

  2. What is your weight?

    A number from 30 to 300

  3. Has a health professional ever told you that your blood pressure is high?

    Choose one:

    • Yes
    • No
    • Never checked or don't know

Medical and Family History

  1. Has a doctor ever told you that you have any of these conditions? Select all that apply.

    Choose any that apply:

    • Diabetes
    • High cholesterol
    • Heart disease
    • Stroke
    • Asthma or COPD
    • Cancer
    • None of these

  2. Have any of your parents, brothers or sisters had any of these? Select all that apply.

    Choose any that apply:

    • Heart disease before age 60
    • Diabetes
    • Stroke
    • Cancer
    • None of these
    • Don't know

Sleep and Stress

  1. On a typical night, how many hours do you sleep?

    A number from 2 to 16

  2. In the past month, how often have you felt stressed?

    Choose one:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Always