Wellness Assessment Form
A wellness self-assessment — rate and reflect on physical activity, nutrition, sleep, stress and mental wellbeing, and lifestyle habits, then set wellness goals. For coaching, wellness programs, or personal check-ins.
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WELLNESS ASSESSMENT Name: Sample Name Date: May 23, 2026 Rate each area honestly and add a note. There are no wrong answers — this is a snapshot to help you and (if applicable) your coach focus. 1. PHYSICAL ACTIVITY Self-rating: 1 2 3 4 5 (1 = needs work, 5 = great) (circle one) Describe your typical week of exercise/movement _________________________________________________ 2. NUTRITION & HYDRATION Self-rating: 1 2 3 4 5 (1 = needs work, 5 = great) (circle one) How would you describe your eating habits and hydration? _________________________________________________ 3. SLEEP Self-rating: 1 2 3 4 5 (1 = needs work, 5 = great) (circle one) How many hours do you sleep, and how rested do you feel? _________________________________________________ 4. STRESS & MENTAL WELLBEING Self-rating: 1 2 3 4 5 (1 = needs work, 5 = great) (circle one) What are your main sources of stress, and how do you cope? _________________________________________________ 5. LIFESTYLE & HABITS Self-rating: 1 2 3 4 5 (1 = needs work, 5 = great) (circle one) Tobacco, alcohol, screen time, social connection — anything to note? _________________________________________________ WELLNESS GOALS Your top 1-3 wellness goals for the next 3 months 1. _______________________________________________ 2. _______________________________________________ 3. _______________________________________________ This is a personal wellness check-in, not a medical assessment. Talk to a licensed healthcare provider about any health concerns.
About this template
A wellness assessment is a structured self check-in across the lifestyle factors that most affect how you feel day to day: physical activity, nutrition and hydration, sleep, stress and mental wellbeing, and habits like alcohol, tobacco, screen time, and social connection. Its value is twofold — a quick **self-rating** (a simple 1–5 per area) turns vague feelings into something comparable you can re-check in a few months and actually see change, and the **open reflection prompts** surface the specifics a number cannot ("I sleep seven hours but wake up tired," "stress spikes on Sunday nights"). Two principles make it useful. First, **answer honestly** — this is a snapshot to work from, not a test to pass; the areas you rate lowest are simply where the most opportunity is. Second, **end with a small number of concrete goals** (one to three), because an assessment that does not lead to a couple of specific, doable changes rarely changes anything. Used in **coaching or workplace-wellness programs**, the form gives a coach a fast, shared picture of where to focus and a baseline to measure progress against; used personally, it is a periodic reset to notice drift before it becomes a problem. Re-take it every quarter, compare your ratings over time, and pick one area to nudge rather than overhauling everything at once. Importantly, this is a **wellness and lifestyle tool, not a medical diagnostic** — it does not screen for or diagnose any condition, and anyone with health concerns, symptoms, or before starting a new exercise or diet program should consult a licensed healthcare provider.
When to use it
- A personal wellness check-in or quarterly reset.
- Onboarding a client for health/wellness or fitness coaching.
- Workplace-wellness or program intake (lifestyle, not medical).
- Establishing a baseline to track lifestyle changes over time.
What to include
- Name and date for tracking over time.
- A 1–5 self-rating for each wellness area.
- Reflection prompts for activity, nutrition, sleep, stress, and lifestyle.
- One to three concrete wellness goals.
- A reminder that it is not a medical assessment.