Executive Wellness
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1
. Please tell me about yourself.
Please tell me about yourself.
Name:
Company:
Address:
Address 2:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code:
Country:
Email Address:
Phone Number:
2
. Rate your satisfaction with the following issues that typically affect wellness.
Completely Dissatisfied
Somewhat Dissatisfied
Neither Satisfied Nor Dissatisfied
Somewhat Satisfied
Completely Satisfied
N/A
Eating habits
*
Rate your satisfaction with the following issues that typically affect wellness. Eating habits Completely Dissatisfied
Eating habits Somewhat Dissatisfied
Eating habits Neither Satisfied Nor Dissatisfied
Eating habits Somewhat Satisfied
Eating habits Completely Satisfied
Eating habits N/A
Sleep habits
Sleep habits Completely Dissatisfied
Sleep habits Somewhat Dissatisfied
Sleep habits Neither Satisfied Nor Dissatisfied
Sleep habits Somewhat Satisfied
Sleep habits Completely Satisfied
Sleep habits N/A
Stress management
Stress management Completely Dissatisfied
Stress management Somewhat Dissatisfied
Stress management Neither Satisfied Nor Dissatisfied
Stress management Somewhat Satisfied
Stress management Completely Satisfied
Stress management N/A
Manage work issues
Manage work issues Completely Dissatisfied
Manage work issues Somewhat Dissatisfied
Manage work issues Neither Satisfied Nor Dissatisfied
Manage work issues Somewhat Satisfied
Manage work issues Completely Satisfied
Manage work issues N/A
Financial issues
Financial issues Completely Dissatisfied
Financial issues Somewhat Dissatisfied
Financial issues Neither Satisfied Nor Dissatisfied
Financial issues Somewhat Satisfied
Financial issues Completely Satisfied
Financial issues N/A
Depression or anxiety
Depression or anxiety Completely Dissatisfied
Depression or anxiety Somewhat Dissatisfied
Depression or anxiety Neither Satisfied Nor Dissatisfied
Depression or anxiety Somewhat Satisfied
Depression or anxiety Completely Satisfied
Depression or anxiety N/A
Weight
Weight Completely Dissatisfied
Weight Somewhat Dissatisfied
Weight Neither Satisfied Nor Dissatisfied
Weight Somewhat Satisfied
Weight Completely Satisfied
Weight N/A
Physical activity
Physical activity Completely Dissatisfied
Physical activity Somewhat Dissatisfied
Physical activity Neither Satisfied Nor Dissatisfied
Physical activity Somewhat Satisfied
Physical activity Completely Satisfied
Physical activity N/A
Alcohol or drugs
Alcohol or drugs Completely Dissatisfied
Alcohol or drugs Somewhat Dissatisfied
Alcohol or drugs Neither Satisfied Nor Dissatisfied
Alcohol or drugs Somewhat Satisfied
Alcohol or drugs Completely Satisfied
Alcohol or drugs N/A
Tobacco
Tobacco Completely Dissatisfied
Tobacco Somewhat Dissatisfied
Tobacco Neither Satisfied Nor Dissatisfied
Tobacco Somewhat Satisfied
Tobacco Completely Satisfied
Tobacco N/A
Medications
Medications Completely Dissatisfied
Medications Somewhat Dissatisfied
Medications Neither Satisfied Nor Dissatisfied
Medications Somewhat Satisfied
Medications Completely Satisfied
Medications N/A
Sense of well being (health & happiness
Sense of well being (health & happiness Completely Dissatisfied
Sense of well being (health & happiness Somewhat Dissatisfied
Sense of well being (health & happiness Neither Satisfied Nor Dissatisfied
Sense of well being (health & happiness Somewhat Satisfied
Sense of well being (health & happiness Completely Satisfied
Sense of well being (health & happiness N/A
Specific medical conditions
Specific medical conditions Completely Dissatisfied
Specific medical conditions Somewhat Dissatisfied
Specific medical conditions Neither Satisfied Nor Dissatisfied
Specific medical conditions Somewhat Satisfied
Specific medical conditions Completely Satisfied
Specific medical conditions N/A
Other (please specify)
3
. The following traits may be helpful building blocks. Which ones are you satisfied with your capability?
The following traits may be helpful building blocks. Which ones are you satisfied with your capability?
Self-sufficiency
High work ethic (work brings satisfaction)
Results oriented
Perseverance (gets the job done regardless)
Stamina (seldom, if ever, gives up)
Other (please specify)
4
. Which of the following wellness, health, and fitness areas are you interested in for goal setting?
Which of the following wellness, health, and fitness areas are you interested in for goal setting?
Physical fitness & well being
Stress reduction
Weight & nutrition
Sleep habits
Depression or anxiety
Physical activity
Sports-related conditioning
Alcohol or drug issues
Tobacco use
Specific medical issues
Relationship issues
Other (please specify)
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