Worksite Wellness

Worksite Wellness

WORKSITE WELLNESS

INTEREST SURVEY

  1. First tell us about yourself:
  2. Male:
  3. Female:
  4. Age Group:
  5. Under 21:
  6. 21-30:
  7. 31-40:
  8. 41-50:
  9. 51-60:
  10. 61+:
  11. Your Department:
  1. I buy healthy snacks when they are available (for ex. Pretzels, cereals, yogurt, fresh fruit, raisins, dried fruit, 1% or skim milk):
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. I would buy healthy snacks at the worksite if they were available:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. If I had a 5-minute break, I would use it for a personal activity – like stretching, or a walk – if there were a place to do it:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. I would eat fruit if available at our staff meetings
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. I would use resource guides for healthy eating or physical activity (for ex. How-to books, videos and recipes) if they were available:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. I am satisfied with my current state of health:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. I make time for 30 or more minutes of physical activity most days of the week:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. I don’t think about health when deciding what to eat:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. It’s hard for me to get as much exercise as I should:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. How likely are you to obtain the recommended 8 hours of sleep a night:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. I try to look for healthier foods, but usually eat whatever is available:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. I regularly use tobacco products (cigarettes or chew):
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. I eat breakfast every day:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. I have had my blood pressure checked within the last year:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. I think that good nutrition and regular physical activity can contribute to better productivity at work:
  2. Very Likely:
  3. Somewhat Likely:
  4. Not Very Likely:
  5. Not at all Likely:
  6. Skipped:
  1. Do you typically take regular breaks during the day?
  2. Yes, most “typical” days:
  3. No, I usually don’t take a break:
  4. Skipped:
  1. If ‘yes’, what breaks do you most often take?
  2. Morning “coffee’ break:
  3. Afternoon break:
  4. Lunch:
  5. Skipped:
  1. If no, you don’t take breaks, why not?
  1. If you could receive written information for 5 of the health topics listed below, which 5 would you select
  2. Tips for reducing cholesterol:
  3. Controlling blood pressure:
  4. Weight management techniques:
  5. Preventive dentistry:
  6. Starting a walking program:
  7. Vitamin facts:
  8. Recipes with fruits & vegetables:
  9. Women’s health:
  10. Starting a physical activity program:
  11. Low salt tips:
  12. Avoiding sports injuries:
  13. Heart disease prevention:
  14. Nutritious cooking tips:
  15. Cancer detection/prevention
  16. Second-hand smoke:
  17. Diabetes:
  18. Medical Self-care:
  19. Nutrition & Cancer prevention
  20. Questions for your doctor:
  21. Tobacco cessation tips/Quit line info:
  22. Sleep disorders:
  23. Breast self-exam:
  24. Recreational safety:
  25. Men’s Health:
  26. Tips for increasing physical activity:
  27. Information on alcohol/drug abuse:
  28. Prevention of STD’s/HIV-AIDS:
  29. Parenting tips:
  30. Adult immunization:
  31. Stretching/Strength tips:
  32. Coping with Stress:
  33. Small steps to changing nutrition/physical activity:
  1. Would you personally participate in a health promotion program if we offered one?
  2. Yes:
  3. No:
  4. Would you participate in any of the following wellness activities on a regular basis if they were offered at work?
  5. Aerobic exercise classes:
  6. Tobacco cessation program:
  7. Weight management program:
  8. Blood pressure screening:
  9. Confidential health screening:
  10. Pot-luck for nutritional foods:
  11. Health Fair:
  12. Blood test for cholesterol:
  13. Fitness or wellness challenge:
  14. Workshop on self-esteem:
  15. Walking event or club:
  16. Workshop on stress management:
  17. Monthly wellness seminar:
  18. Healthy cooking classes:
  19. Other:
  1. If you were to receive information about activities, health topics, news or tips about healthy choices, what would be your preferred way to get that information?
  2. A dedicated bulletin board:
  3. Weekly e-mail tips:
  4. In a flyer distributed with paychecks:
  5. On the intranet:
  6. Discussion at staff meetings:
  7. Other:
  1. Would you be more likely to participate in a wellness program if there were incentives?
  2. Most likely, Yes:
  3. Probably Not:
  1. If ‘yes’, what incentives would motivate you?
Top View