Lifestyle & Wellness Survey
RequiredRequired Question(s)
Required 1.
Consider where you are in your life and rate accordingly.
 (High) (Somewhat High) (Average) (Somewhat Low) (Low) 0 (No Opinion) 
Mindfulness: Awareness of the present moment; paying attention to what you are doing while you are doing it.
Movement & Rest: Activities of daily living & exercise balanced with adequate rest & relaxation.
Nutrition: Eating a balanced, healthy diet.
Relationships & Communication: Time, positive support & effective interaction with family, friends/co-workers.
Mind-Body Connection: Attentive to interconnectedness of mind & body (breathing practices, meditation, etc.)
Preventive Care & Intervention: Routine health screenings, vitamin/supplement usage, complementary treatment(s)
Spirituality: Seeing purpose and meaning in something larger than one's self; may include religion, nature, or the arts
  • Comment:

  • 500 characters left.
Required 2.

To improve your wellness level and reduce you risk of lifestyle-related disease, what are some of your goals?  Check all that apply.

Weight Control/ Weight loss
Manage Stress
Sleep More, Improve Sleep Quality
Be More Active, Develop Regular Exercise Habits
Eat better, Choose/ Prepare healthier foods
Better manage chronic health complaint or condition
Lower blood pressure
Lower Cholesterol
Decrease sugar intake, improve glucose level
Stop Smoking
Other  
  • Comment:

  • 500 characters left.
Required 3.

What factors influence your ability to achieve your goal(s)?  Check all that apply.

Fast Food, Junk Food
Late Night Snacking
Staying Up Late
Sweet Snacks
Carbonated Drinks
Skipping Meals
Stress Eating/ Anxiety
Fad Diets
Travel (business or personal)
Inadequate Portion Control
Medications
Time Challenged
Chronic Pain/ Injury
Can't Cook/ Don't like to cook
Lack of Knowledge
Sleep Deprevation
Physical Limitations/ Health Condition(s)
Smoking
Other  
  • Comment:

  • 500 characters left.
Required 4.
On average, how many hours of sleep do you get each night?
less than 5 hours
less than 5 during the week and more on the weekend
5 to 6 hours
5 to 6 hours during the week and more on the weekend
6 to 7 hours
6 to 7 hours during the week and more on the weekend
7+ hours
  • Comment:

  • 500 characters left.
Required 5.
Have you ever been told by a healthcare provider that you are at-risk for a chronic health condition or have a chronic health condition?  Examples include:  Arthritis, Asthma, Migraines, Inflammatory bowel disease or colitis, pulmonary disease, heart disease, high blood sugar or diabetes, high blood pressure, high cholesterol, high tryglycerides, obesity, osteoporosis, stroke, etc.
Yes
No
Other  
Required 6.
What was your results for the following when last checked?
 Optimal Level Near Optimal/ Desirable Mid-Range Borderline High High Low I'm Not Sure/ Never Checked 
Total Cholesterol
LDL (bad) Cholesterol
HDL (good) Cholesterol
Triglyceride Level
Fasting Blood Glucose (blood sugar)
Hemoglobin A-1C (measures risk for diabetes)
CRP: C-Reactive Protein (measures inflammation)
Required 7.

In general, how would you describe your overall health?

Excellent
Very Good
Good
Fair
Poor
NUTRITION
 
Required 8.

How many 8-ounce servings of water do you drink per day?

10+
7-9
4-6
1-3
Required 9.
In a typical week, how many times do you:
 Daily 5 - 6 3 - 4 1 - 2  
Cook at home?  
Eat fast food take-out/ drive-thru?  
Dine at a restaurant?  
Eat a nutritious breakfast?  
Required 10.

In a typical day, how many servings do you have of:

 None 5+ 
Fruit? (1 serving = 1 cup fresh, frozen or canned; 1/2 cup 100% juice or dried fruit
Vegetables? (1 serving = 1 cup raw or 1/2 cup cooked)
Unhealthy Snacks (high sugar or high fat)
Caffeine (coffee, tea)
Required 11.

When you buy fruits and vegetables, which do you buy more of?

Frozen
Fresh
Canned
Required 12.

Where do you usually shop for food?  (check all that apply)

Supermarket Chain (Kroger, Tom Thumb, Wal-Mart)
Health Food Store (Sprouts, Whole Foods, Market Street, Central Market)
Warehouse Supermarket (Costco or Sam's Club)
Farmers' Market
Other  
Required 13.

Which do you consider when selecting foods to eat?  (check all that apply)

Flavor of the food
What I or family wants
Convenience (quick to prepare or pick up)
Availability of food
Costs of food
Nutrition of food
Foods I ate growing up
Don't really think about it
Texture or smell of food
Other  
Required 14.

Before buying food, how often do you read the nutritional labels?

100% of the time
75% of the time
50% of the time
25% of the time
Never
I'm not sure I know how to read label correctly
EXERCISE
 
Required 15.

Are you self-motivated to exercise on your own?

Yes
No
Required 16.

Are you currently involved in regular endurance (cardiovascular) exercise lasting a minimum of 30-minutes?

Yes, 1-2 times a week
Yes, 3-4 times a week
Yes, 5-6 times a week
No
  • Comment:

  • 500 characters left.
Required 17.
At what intensity do you typically exercise?
Light (stretching or slow walking)
Moderate (brisk walking)
Heavy (joggin or swimming)
Very heavy (fast running or stair climbing)
I don't exercise
Required 18.

How many days per week do you typically participate in strength training (for example lifting weights, using resistance bands, doing pushups)?

1 - 2
3 - 4
5+
I don't participate in strength training
Required 19.
How many days per week do you typically do flexiblity exercises or stretching?
1 - 2
3 - 4
5+
I don't stretch or engage in flexibility exercises
  • Comment:

  • 500 characters left.
SUN PROTECTION
 
Required 20.

Does your skin burn easily when exposed without sunscreen to a strong sun?

Yes
No
Required 21.

When you spend time in the sun, do you usually wear protective clothing or apply sunscreen with a SPF of at least 15?

Yes
No
Other  
Required 22.

How many times during your lifetime has your skin been severly sunburned?

0 - 1
2 - 3
4+
SAFETY
 
Required 23.

Do you always wear a seatbelt when you drive or ride in a motor vehicle?

Yes
No
Required 24.

Do you have a working smoke detector(s) in your home? 

Yes
No
Required 25.
Do you know CPR?
Yes; compression, hands-only
Yes; breath & compressions
No
  • Comment:

  • 500 characters left.
HEALTHCARE
 
Required 26.

Do you have a primary health care provider (doctor, nurse or other licensed health professional) who will provide you with general health care and referrals to other health professionals when necessary?

Yes
No
Required 27.

Have you had a health checkup (physicial exam) within the past year?

Yes
No
Required 28.

Have you had a dental exam by a dentist within the past 12-months?

Yes
No
YOUR INFORMATION
 
Required 29.
Please enter the information indicated below.

First Name:
Last Name:
Company Name:
Email Address:
emailaddress@xyz.com
City:
Postal Code:

Required 30.

Date of Birth (MM-DD-YEAR):

 

50 characters left.
Required 31.
What is the phone number to reach you?  Please indicate if mobile #, home or work.
 

50 characters left.