A health risk assessment survey is taken by a medical professional in order to identify the risk factors that the patient is susceptible to. This survey seeks information regarding the factors that act as potential risk for the health conditions of the patient. After the survey questions are assessed and based on the answers provided the patient the treatment and precautions are advised accordingly by the medical professional. This survey helps the patient in mitigating future health risks and undertaking corrective steps well in advance before health problems strike.

This survey also helps insurance companies in arriving at the coverage that needs to be provided based on the health risk factors covered here.

Sample Health Risk Assessment Survey

Name of the patient –

Age of the patient –

Weight of the patient –

Height of the patient –

Address of the patient –

Contact number of the patient –

Email address of the patient –


1. Do you have any of the following habits at present?

a. Smoke pipe, cigarette, cigar or hookah etc

b. Consume alcoholic beverages every day.

c. Usually get angry for trivial things at home and office.

d. Eat deep fried food more than three times in a week.

2. What is the kind of fitness you follow every day?

a. Take a brisk walk

b. Go for swimming

c. Workout in a gymnasium

d. Do not exercise at all

3. How many hours of sleep do you get every day?

a. Six hours

b. Seven hours

c. Eight hours

d. Nine hours

4. What are all the things you include in your meals every day?

a. At least three servings of fruits

b. Eat green leafy vegetables every day

c. Include dairy products in every meal.

d. Do not follow a strict diet

5. On a scale of 1 to 5 in which 1 is the least and 5 is the best how do you rate your health?



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