Corporate wellness program coordinators
Collects lifestyle and medical history data from employees as part of an annual wellness incentive program to identify high-risk individuals for targeted interventions.
Health Risk Assessment Template
Give individuals a clear picture of their lifestyle health risks with this comprehensive assessment. Covering physical activity, diet quality, smoking status, alcohol consumption, stress, sleep, family medical history, and preventive care, this template provides a holistic health profile that wellness coaches, HR teams, and healthcare providers can use to drive meaningful conversations about behavior change.
Free for non-commercial projects, with unlimited forms and responses.
Last updated
About this template
A health risk assessment (HRA) is a foundational tool in wellness programs, preventive care, and corporate health initiatives. By collecting self-reported data on lifestyle behaviors and medical history, an HRA helps identify individuals who are at elevated risk for chronic conditions like heart disease, type 2 diabetes, and mental health disorders — before those conditions develop into costly medical events.
More about this template
This template covers the eight lifestyle domains most strongly linked to long-term health outcomes in peer-reviewed research: physical activity, diet quality, tobacco use, alcohol consumption, stress, sleep, family medical history, and engagement with preventive care. Each question uses a validated categorical format that allows straightforward risk stratification — scoring respondents from low risk to high risk across each domain.
formformform makes it easy to collect HRA data from employees, patients, or program participants at scale. Results are stored in a central dashboard and exportable to your wellness platform or EHR system. The confidentiality notice in the template intro helps build trust and encourage honest, accurate responses — which is essential for any health assessment to be useful.
11 fields to make your own11 required in this starting form
Make it fit your workflow.
Use your own copy to change labels, remove questions and add the details you need. Try the preview alongside this guide to see what respondents will be asked.
The questions, explained
Fields in this template
Review the starting questions and choices. You can change them in your own copy.
Full Name
Jane Smith
Email Address
jane@example.com
Date of Birth
How often do you engage in moderate to vigorous physical activity?
4 choices
- 5 or more days per week
- 3–4 days per week
- 1–2 days per week
- Rarely or never
How would you rate the overall quality of your diet?
4 choices
- Excellent — mostly whole foods, fruits, and vegetables
- Good — generally healthy with occasional indulgences
- Fair — processed foods are a significant part of my diet
- Poor — my diet is mostly processed or fast food
What is your current smoking status?
4 choices
- Never smoked
- Former smoker (quit more than 1 year ago)
- Former smoker (quit within the past year)
- Current smoker
How often do you consume alcohol?
4 choices
- Never
- Occasionally (1–2 drinks per week)
- Moderately (3–7 drinks per week)
- Frequently (8+ drinks per week)
How would you rate your typical stress level?
4 choices
- Low — I manage stress well most of the time
- Moderate — stress is present but manageable
- High — I often feel overwhelmed or anxious
- Very high — stress significantly affects my daily life
How many hours of sleep do you typically get per night?
4 choices
- 8 or more hours
- 7–8 hours
- 5–6 hours
- Fewer than 5 hours
Do you have a family history of any of the following conditions?
4 choices
- Heart disease or stroke
- Type 2 diabetes
- Cancer (any type)
- None of the above / I'm not sure
When did you last have a routine physical exam?
4 choices
- Within the past year
- 1–2 years ago
- 3–5 years ago
- More than 5 years ago / Never
Where it fits
Who uses this template
Suggested uses, and why this starting point can help. Adapt the questions to your own process.
Health coaches and nutritionists
Gives health coaches a complete lifestyle baseline before their first session with a new client so they can prioritize the highest-impact behavior changes.
Primary care practices
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “How would you rate the overall quality of your diet?” in particular and adapt it to the detail you need.
Insurance brokers and benefits managers
Replace scattered requests with a consistent starting point. The answers help you understand the work, identify gaps and prepare a follow-up. Review “What is your current smoking status?” in particular and adapt it to the detail you need.
Fitness centers and gyms
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “How often do you consume alcohol?” in particular and adapt it to the detail you need.
Employee assistance programs (EAPs)
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “How would you rate your typical stress level?” in particular and adapt it to the detail you need.
Public health organizations
Gather the details needed before making arrangements. Consistent answers help you spot special requirements and prepare the next step. Review “How many hours of sleep do you typically get per night?” in particular and adapt it to the detail you need.
Telehealth platforms
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “Do you have a family history of any of the following conditions?” in particular and adapt it to the detail you need.
What's included
10 lifestyle and medical history questions across four health domains
Date of birth field for age-based risk stratification
Confidentiality notice in the intro paragraph
Organized sections: Lifestyle, Mental Health & Sleep, Medical History
Dividers and section headings for easy navigation
Instant submission notification with full health profile
All data stored securely and exportable for wellness program tracking
Unlimited submissions at no cost
How to create a health risk assessment
- 1
Click 'Use this template' to open the health risk assessment in formformform's editor.
- 2
Update the confidentiality notice in the intro paragraph to reference your organization's privacy policy.
- 3
Add or remove lifestyle questions to match the specific health risks relevant to your program population.
- 4
Adjust the answer options for any question to align with your organization's clinical guidelines or scoring rubric.
- 5
Set up email notifications so each completed assessment reaches your wellness coordinator or clinical team.
- 6
Share the link with employees, patients, or program participants, or embed it in your wellness portal or patient intake workflow.
Best practices for your health risk assessment
Include the confidentiality notice
participation rates drop significantly when respondents aren't sure how their health data will be used. Be explicit about privacy protections.
Use age from date of birth for risk stratification
age is one of the strongest modifiers of health risk. Capturing date of birth lets you segment results and tailor follow-up recommendations by age group.
Follow up with personalized guidance
an HRA is only valuable if it drives action. Send each respondent a follow-up with their top two or three areas of risk and a specific recommended next step.
Keep the medical disclaimer visible
always clarify that the assessment does not constitute medical advice and encourage respondents to consult a healthcare provider.
Run it annually
repeat the assessment each year so participants can track their lifestyle improvements and identify emerging risks.
Aggregate results for population-level insights
for corporate programs, analyze aggregate data to identify the top health risks across your workforce and design targeted interventions.
12 form ideas you can build with this template
Corporate Employee Wellness HRA
Collects lifestyle and medical history data from employees as part of an annual wellness incentive program to identify high-risk individuals for targeted interventions.
Health Coach Client Intake Assessment
Gives health coaches a complete lifestyle baseline before their first session with a new client so they can prioritize the highest-impact behavior changes.
Gym Member Health Screening
Screens new gym members for cardiovascular risk factors before they begin a high-intensity exercise program.
Life Insurance Underwriting Pre-Screen
Collects self-reported lifestyle risk factors from applicants as part of an initial underwriting screening before a full medical exam.
College Student Wellness Assessment
Identifies stress, sleep deprivation, and poor diet habits in incoming students to guide wellness center programming and outreach.
Remote Worker Health Check-In
Monitors lifestyle changes — particularly stress, sleep, and physical activity — in distributed workforces where sedentary behavior and isolation are elevated risks.
Senior Living Community Health Screen
Collects health status, physical activity levels, and family history from prospective residents to determine appropriate care placement.
Diabetes Prevention Program Screener
Identifies individuals with lifestyle risk factors for type 2 diabetes — poor diet, low activity, high stress — for enrollment in a prevention program.
Occupational Health Baseline Assessment
Documents lifestyle health status for workers in high-risk industries like construction, mining, or heavy manufacturing at the time of hire.
Pregnancy Wellness Self-Assessment
Collects diet, sleep, stress, and exercise data from expecting mothers to help midwives and OBs prioritize wellness coaching conversations.
Mental Health Risk Screener
Flags employees or patients with high stress, poor sleep, and social isolation for proactive mental health support outreach.
Telehealth Pre-Visit Health History
Captures lifestyle and family medical history before a virtual primary care appointment so the provider can focus consultation time on high-priority concerns.
Frequently asked questions
Is this health risk assessment HIPAA-compliant?
formformform is a general-purpose form builder and does not offer a Business Associate Agreement (BAA). If you are collecting protected health information (PHI) in a healthcare context, you should consult your compliance team and use a HIPAA-compliant platform for storing and processing the data.
Can I use this for corporate wellness programs?
Yes. This is one of the most common use cases. Share it with employees as part of an annual wellness initiative, collect aggregate results to identify population-level health risks, and use the data to design targeted wellness interventions.
How do I score the health risk assessment?
Each question's answer options are ordered from lowest to highest risk. Assign point values (e.g., 0–3) to each option and sum across all questions to generate a total risk score. Export the data to a spreadsheet to calculate and categorize scores at scale.
Can I add questions about specific chronic conditions or medications?
Yes. You can add any additional fields — radio buttons, checkboxes, or open-ended text — using the form builder. Common additions include BMI range, blood pressure status, and current medication use.
Will respondents' health data be kept private?
formformform stores submission data securely and does not share it with third parties. However, as the form owner, you are responsible for communicating your privacy practices to respondents and complying with applicable data protection laws.
Can I embed this assessment in our employee wellness portal?
Yes. formformform provides an iframe embed code that works on any website or intranet portal. You can also share a direct link via email or your HR information system.
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