Product

Product Tour See how FormBuilder works Templates Ready-made form templates Marketplace Expert-made forms and tests Use Cases Forms for every industry Security Enterprise-grade data protection Integrations Connect with your tools Changelog Latest updates and releases
Features

Form Builder
Drag & Drop Builder Form Field Types Multi-Page Forms Conditional Logic Form Embedding

Form Analytics
Submissions Real-Time Submissions Form Analytics Email Notifications Form Scheduling

Themes
Themes White Label Team Collaboration Audit Log Assessment Mode Google Forms Import

All Features See every feature we offer
AI

AI Overview

Our AI-powered features

Cook it AI

Generate forms from text or files

Generate

Pulse AI

AI insights on your form data

Analyze

Edit AI

Rewrite and refine forms in place

Edit
Solutions

Solutions
Form Builder Build any form from scratch AI Form Builder Generate forms with AI Online Forms Create and share forms online Survey Maker Build surveys and collect feedback Quiz Maker Create graded quizzes and tests Assessment Platform Proctored exams with lockdown Appointment Scheduling Booking forms with calendar

Compare
vs Google Forms vs Typeform vs JotForm vs SurveyMonkey vs Microsoft Forms All Comparisons →
Pricing

Demographic Survey · Popular

Community Health & Wellness Demographic Survey

Gather vital demographic, socioeconomic, and health data from community members to identify needs and improve wellness programs.

Use This Template Free Preview

Peach theme

formbuilder.ai/f/community-health-wellness-demographic-profile-survey

Community Health & Wellness Demographic Profile Survey

Full Name

· · ·

Email Address

· · ·

Phone Number

· · ·

Submit

The Community Health & Wellness Demographic Profile Survey is a comprehensive data-collection tool designed to help public health organizations, nonprofits, hospitals, and community groups better understand the populations they serve. By capturing personal, household, socioeconomic, and health information in one streamlined form, you can identify gaps in care and tailor wellness initiatives accordingly.

This template covers key demographic fields such as age range, gender identity, race/ethnicity, preferred language, education level, employment status, and household income — alongside critical health metrics like self-rated health, chronic condition management, primary care access, and physical activity habits. Together, these data points paint a holistic picture of community health status and social determinants of health.

Whether you're conducting a community needs assessment, preparing grant applications, or planning targeted outreach programs, this survey template saves you time while ensuring you collect the right information. Fully customizable and easy to distribute online, it helps you turn raw responses into actionable insights that drive meaningful, data-backed health improvements.

4 Pages

23 Questions

~8min To complete

Free No credit card needed

Field types Dropdown ×9 Multiple Choice ×3 Single Choice ×2 Likert Scale ×2 Full Name Email Phone number Yes / No Long Text termsandconditions

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Personal Information 7 questions

Personal Information

1 Full Name * Full Name

2 Email Address * Email

3 Phone Number Phone

4 Age Range * Dropdown

5 Gender Identity * Single Choice

6 Race/Ethnicity (select the one you most identify with) * Dropdown

7 Preferred Language * Dropdown

Page 2 Household & Socioeconomic Background 6 questions

Household & Socioeconomic Details

1 Marital Status * Dropdown

2 Number of People in Your Household (including yourself) * number

3 Highest Level of Education Completed * Dropdown

4 Employment Status * Dropdown

5 Annual Household Income Dropdown

6 Health Insurance Status * Dropdown

Page 3 Health & Wellness Profile 6 questions

Health & Wellness Information

1 How would you rate your overall health? * Single Choice

2 Do you currently manage any of the following conditions? (Select all that apply) * Multiple Choice

3 Do you have a primary care physician or regular healthcare provider? * Yes / No

4 How often do you engage in physical activity (30+ minutes)? * Dropdown

5 I have adequate access to healthy and affordable food in my community * Likert Scale

6 What are your top health and wellness concerns? (Select up to 3) * Multiple Choice

Page 4 Community Access & Final Thoughts 4 questions

Community Resources & Feedback

1 Which community health resources have you used in the past 12 months? (Select all that apply) Multiple Choice

2 I feel that health and wellness resources in my community are easy to access * Likert Scale

3 What health or wellness services would you most like to see improved or added in your community? Long Text

4 I consent to my responses being used anonymously for community health planning and research purposes. * termsandconditions

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.