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.
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Fields in this template
- Full Namerequired
- Email Addressrequired
- Date of Birthrequired
- How often do you engage in moderate to vigorous physical activity?required
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?required
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?required
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?required
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?required
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?required
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?required
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?required
Within the past year · 1–2 years ago · 3–5 years ago · More than 5 years ago / Never
Who uses this template
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.
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.
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.
What's included
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
participation rates drop significantly when respondents aren't sure how their health data will be used. Be explicit about privacy protections.
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.
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.
always clarify that the assessment does not constitute medical advice and encourage respondents to consult a healthcare provider.
repeat the assessment each year so participants can track their lifestyle improvements and identify emerging risks.
for corporate programs, analyze aggregate data to identify the top health risks across your workforce and design targeted interventions.
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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