Personal Health and Wellness Check-In Form

Personal Health and Wellness Check-In Form — Form Fields

This personal template includes 12 fields. A regular self-assessment form for tracking personal health habits, energy levels, and wellness goals. Free to customize and use on ZenBuild.

• Your Name (text, required)
• Check-In Date (text, required)
• Overall health rating this week (1-5) (rating, required)
• Average hours of sleep per night (number, required)
• Days exercised this week (number, required)
• Diet quality this week (dropdown selection, required) — options: Excellent, Good, Fair, Poor
• Glasses of water per day (average) (number, required)
• Stress level this week (dropdown selection, required) — options: Very low, Low, Moderate, High, Very high
• Health wins this week (long text, optional)
• Health challenges this week (long text, optional)
• Did you take any time for mental health this week? (dropdown selection, required) — options: Yes - meditation, Yes - journaling, Yes - therapy, Yes - other, No
• Goals for next week (long text, optional)