--- title: "Free Health Risk Assessment Template | formformform" description: "Free health risk assessment template. Evaluate lifestyle factors including exercise, diet, smoking, stress, sleep, and family medical history — ideal for…" url: "https://www.formformform.com/templates/health-risk-assessment-form" type: static generatedAt: "2026-09-16T13:11:47.237Z" --- [Templates](https://www.formformform.com/form-templates)/[Quizzes & Assessments Forms](https://www.formformform.com/form-templates/quizzes-forms) # 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. [Use this template](https://app.formformform.com/templates/health-risk-assessment-form/use) Last updated 21 August 2026 ## Fields in this template - Full Name · required - Email Address · required - Date of Birth · required - 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 Corporate wellness program coordinators · Health coaches and nutritionists · Primary care practices · Insurance brokers and benefits managers · Fitness centers and gyms · Employee assistance programs (EAPs) · Public health organizations · Telehealth platforms ## 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 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. 1 Click 'Use this template' to open the health risk assessment in formformform's editor. 2. 2 Update the confidentiality notice in the intro paragraph to reference your organization's privacy policy. 3. 3 Add or remove lifestyle questions to match the specific health risks relevant to your program population. 4. 4 Adjust the answer options for any question to align with your organization's clinical guidelines or scoring rubric. 5. 5 Set up email notifications so each completed assessment reaches your wellness coordinator or clinical team. 6. 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. ## 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. ## Related templates [Quizzes & Assessments Forms Personality Quiz Template Reveal personality types with an engaging 10-question quiz.](https://www.formformform.com/templates/personality-quiz-form)[Quizzes & Assessments Forms Leadership Style Assessment Assess leadership behaviors across decision-making, communication, and delegation.](https://www.formformform.com/templates/leadership-assessment-form)[Healthcare Forms Health Screening Questionnaire Screen visitors, staff or a booked patient for symptoms before they arrive. Questions written 22 August 2026 — review them before publishing.](https://www.formformform.com/templates/health-screening-questionnaire)[Surveys & Feedback Forms Employee Satisfaction Survey Measure employee satisfaction across six key workplace dimensions.](https://www.formformform.com/templates/employee-satisfaction-survey)[Surveys & Feedback Forms Net Promoter Score Survey Measure customer loyalty with a simple 0–10 NPS question.](https://www.formformform.com/templates/nps-survey-form)[Quizzes & Assessments Forms Employee Skills Assessment Quiz Evaluate employee competencies across 10 key workplace skills.](https://www.formformform.com/templates/employee-skills-quiz-form) ## More Quiz & Assessment form templates - [Fun Trivia Quiz template](https://www.formformform.com/templates/fun-trivia-quiz-form) - [Knowledge Assessment Test template](https://www.formformform.com/templates/knowledge-test-form) - [Product Finder Quiz template](https://www.formformform.com/templates/customer-product-quiz-form) [View all Quiz & Assessment form templates →](https://www.formformform.com/form-templates/quizzes-forms) Start with the Health Risk Assessment template Free forever. No credit card required. Customize everything. [Use this template](https://app.formformform.com/templates/health-risk-assessment-form/use)