Executive Health Survey Form
Please complete this brief survey to help us understand your current wellness habits and needs. Your responses are confidential and will be used to guide executive wellness programs.
Overall, how would you rate your current level of well-being?
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1
2
3
4
5
Which of the following best describes your typical physical activity each week?
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Sedentary (little or no exercise)
Light activity (1-2 days per week)
Moderate activity (3-4 days per week)
Active (5+ days per week)
Other
How would you describe your typical eating habits?
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Balanced and healthy
Somewhat healthy
Needs improvement
Other
On average, how many hours of quality sleep do you get per night?
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Less than 5 hours
5-6 hours
7-8 hours
More than 8 hours
How frequently do you feel stressed at work?
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Rarely
Occasionally
Frequently
Almost always
Which wellness topics are you most interested in? (Select all that apply)
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Stress management
Nutrition
Physical activity
Sleep improvement
Work-life balance
Other
How would you rate your current work-life balance?
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1
2
3
4
5
What is your primary motivation for improving your wellness?
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Personal health
Professional performance
Family and relationships
Other
Please share one wellness goal you would like to achieve this year.
Would you be interested in participating in executive wellness workshops or coaching?
Yes
No
Maybe
Submit Survey
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