Patient Lifestyle Habits Survey Template

Template Instructions

The patient lifestyle habits survey template captures insights into patients' daily routines, dietary habits, physical activity levels, and overall lifestyle choices. This free survey template aids healthcare professionals in understanding the broader context of a patient's health and well-being, enabling them to provide more personalized and effective care. Tailored to gather crucial lifestyle information effortlessly, this survey template is an essential addition to any patient assessment toolkit. Click "Use This Template" to start.


Patient Lifestyle Habits Survey Template

11
Questions
Use This Template

Patient Lifestyle Habits Survey Template

Please answer the following questions to the best of your ability. Your responses will help us understand your lifestyle habits and how they may affect your health.
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Personal Information
*
1.
Age Group:
Under 18
18-30
31-45
46-60
Above 60
*
2.
Gender:
Male
Female
Prefer not to say
Lifestyle Habits
*
3.
How would you rate your overall diet?
Very healthy
Somewhat healthy
Not very healthy
Unhealthy
*
4.
How often do you engage in physical exercise?
Daily
Several times a week
Once a week
Rarely
Never
*
5.
On average, how many hours of sleep do you get per night?
Less than 5 hours
5-6 hours
7-8 hours
More than 8 hours
*
6.
Do you smoke tobacco products?
Yes
No
*
7.
How often do you consume alcoholic beverages?
Daily
Several times a week
Once a week
Rarely
Never
*
8.
How often do you experience stress in your daily life?
Very frequently
Occasionally
Rarely
Never
Health and Well-being
*
9.
Do you have any chronic health conditions? (e.g., diabetes, hypertension)
Yes (Please specify)
No
*
10.
How often do you visit a healthcare provider for a check-up?
More than once a year
Once a year
Every 2-3 years
Rarely
Never
Additional Information
11.
Is there any other lifestyle habit or health concern you think we should know about?
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