Health and Wellbeing Questionnaire

Impact of well being program

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Thank you for taking the time to complete this Health and Wellbeing questionnaire. Your responses will help us see the impact of our well being program and show the progress of your current state of health and wellbeing. Please answer all questions as honestly and accurately as possible.

How would you rate your overall health?

Excellent
Good
Fair
Poor

Have you experienced any of the following health issues since the last well being program

Headaches
Digestive issues (e.g. bloating, constipation, diarrhea)
Respiratory issues (e.g. coughing, wheezing, shortness of breath)
Skin issues (e.g. rash, hives, itching)
None of the above

How many hours of sleep do you typically get per night?

Less than 5 hours
5-6 hours
6-7 hours
7-8 hours
More than 8 hours

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