Wellness Assessment Form Template
A free wellness assessment for health coaches and holistic practitioners. Clients rate sleep, stress, energy, movement and more, and share their goals.
Customize the pages and design to fit your needs.
About this template
A whole person wellness questionnaire that covers sleep, energy, stress, movement, food, relationships, purpose, work and money. Use it at the start of a program and again later to see what changed.
Common uses
- Health and wellness coaches
- Holistic practitioners and wellness spas
- Programs measuring progress over time
Key features
- Ten simple wellness scales
- Simple 1 to 5 scales
- Goals in the client's own words
What this template asks
What's your full name?
Short Text
What's your email address?
Email
How many hours do you usually sleep?
Single Choice · Less than 5, 5 to 6, 7 to 8, More than 8
How rested do you feel when you wake up?
Opinion Scale
How would you rate your energy during the day?
Opinion Scale
How stressed do you feel most days?
Opinion Scale
How many days a week do you move for 30 minutes or more?
Single Choice · 0, 1 to 2, 3 to 4, 5 or more
How well do you eat most days?
Opinion Scale
How connected do you feel to friends and family?
Opinion Scale
How much meaning or purpose do you feel in your life?
Opinion Scale
How do you feel about your work?
Opinion Scale
How secure do you feel about money?
Opinion Scale
Which areas would you like help with?
Multiple Choice · Sleep, Stress, Energy, Movement, Food, Relationships, Purpose, Work and life balance
What would feeling well look like for you in 3 months?
Long Text
How to use this template
Copy it
Select Use template and a copy opens in your workspace as an unpublished draft.
Make it yours
Edit any question or answer, choose a theme, and add your logo.
Share it
Publish, then send the link, show a QR code, or embed the form on your site. Responses arrive in Submissions.
Frequently asked questions
What does a wellness assessment cover?
Sleep, energy, stress, movement, food, relationships, purpose, work and money, based on the 8 dimensions of wellness, plus the areas the client wants help with.
Who uses a wellness questionnaire?
Health and wellness coaches, holistic practitioners, wellness spas and retreat hosts who want a full picture of a client before they start working together.
Can I track progress over time?
Yes. Send the same form at the start and end of a program, then compare each client's answers in Google Sheets.