A health assessment survey is one that is used to evaluate the health condition of the person who is taking the survey. The prime objective of this survey is to understand the lifestyle of the individual along with identifying the factors that are responsible for the health of the individual. In this survey the questions are very simple and not very elaborate. The individual filling in the survey has to identify the factors that match his health condition most appropriately and answer the questions asked in the survey. Thus this survey also helps in having a comparison of the state of health of the individual after certain period of time and evaluates the progress or regress accordingly.

Sample Health Assessment Survey

Name of the health assessee:-

Contact number of the health assessee:-

What are the things you do on a daily basis in order to keep yourself healthy?

a)      Go for a walk or jogging every day.

b)      Have a good healthy and nutritious diet.

c)      Have a health check up every quarter to rule out health issues.

d)     All of the above

Do you have parental history of any of the below specified diseases?

a)      Hypertension

b)      Heart diseases

c)      Cancer

d)     Diabetes

Have any of your parents or blood relatives suffered with any mental disorders or psychological disorders at any pint of time in their life?

a)      Yes

b)      No

c)      Not sure

Are you under medication for any diseases that you are suffering from for over the past six months?

a)      Yes pl specify the medication if you have answered yes to this question _____________

b)      No

What do you think about your overall health?

a)      I am very healthy and fit

b)      I am not so healthy and fit

c)      I have some health problems but I try to keep myself fit

d)     I do not have any health problems but I do not do anything to keep myself fit

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