Annual Wellness Questionnaire

Annual Wellness Questionnaire — Form Fields

This healthcare template includes 8 fields. Gathers lifestyle, preventive care, and health status information for annual wellness visits. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Date of Birth (text, required)
• Do you currently smoke or use tobacco products? (multiple choice, required) — options: Yes, No, Former smoker
• How often do you exercise per week? (dropdown selection, required) — options: Never, 1–2 days, 3–4 days, 5+ days
• How would you describe your diet? (multiple choice, required) — options: Excellent, Good, Fair, Poor
• Preventive screenings completed in the past year (checkboxes, optional) — options: Blood pressure check, Cholesterol test, Blood glucose test, Dental exam, Eye exam
• Rate your overall health this past year (rating, required)
• Any new health concerns or questions for your provider? (long text, optional)