Employee Wellness Needs & Interests
1
. Sex
Sex
Male
Female
2
. Which category below includes your age?
Which category below includes your age?
Under 21
21-29
30-39
40-49
50-59
60 or older
3
. In general, how would you rate your overall health?
In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
4
. Do you currently smoke cigarettes, or not?
Do you currently smoke cigarettes, or not?
Yes, I do
No, I do not
5
. How do you feel about your weight?
How do you feel about your weight?
I am about the right weight.
I would like to lose weight.
I am more than 20 pound over my ideal weight.
6
. What do you most often do for exercise?
What do you most often do for exercise?
Lift weights
Walk
Run
Hike
Swim
Dance
Aerobics
Pilates
Play a team sport
Kick boxing
Strength training
Other (please specify)
7
. Would you like Allen to conduct a wellness program?
Would you like Allen to conduct a wellness program?
Yes
No
8
. If you answered yes to the previous question, in which of the following activites would you consider participating?
If you answered yes to the previous question, in which of the following activites would you consider participating?
Aerobic exercise
Weight management
Smoking cessation
Confidential Health Screening
Coping with stress
Alcohol/drug abuse education
Safety/accident prevention
Parenting
Walking program
Health fair
Blood test for cholesterol
Cancer screening
CPR training
Regular wellness presentations
Retirement planning
Back pain
Medical self-care
Stretching program
Healthy sleeping habits
9
. When would you most likely participate? (Please check all that apply.)
When would you most likely participate? (Please check all that apply.)
Monday
Tuesday
Wednesday
Thursday
Friday
Spring
Summer
Fall
Winter
A.M., before lunch
Lunchtime
P.M., after work
Evening
10
. Any additional comments:
Any additional comments:
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