Health Check-In Survey Template

NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information.

Keep your office running smoothly by getting a snapshot of patients’ overall health—before they come in for their first visit. Send patients this survey template so that your staff can set priorities for which issues to address. Get a picture of patients’ basic health by sending this survey first, so that they don’t have to take the time to fill out a paper survey in your office.

This template allows you to ask patients about their exercise level, their smoking and drinking habits, as well as how much they sleep each night. Additionally, you can collect information about patients’ height and weight, so that you can assess their BMI—all before they set foot in your office. Getting this information early can let your office move more efficiently and give your staff an idea of which issues to address first.

All you have to do to start using the Health Check-In survey template is sign up or sign in to SurveyMonkey.

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