Employee Wellness Assessment Form
Please complete this form to help us understand your current health and wellness status. Your responses will assist us in tailoring a wellness program to meet your individual needs.
Personal Information
Date: | [Month Day, Year] |
Employee Name: | [Your Name] |
Department: | [Your Work Department] |
Position: | [Role/Position] |
Date of Birth: | [Month Day, Year] |
Gender: | | |
Contact Number: | [Phone Number] |
Email Details: | [Email Address] |
Health Information
Question | Response (Yes/No) | Details/Comments |
Do you have any known allergies? | No | |
Are you currently taking any medications? | | |
Do you have any chronic health conditions? | | |
Have you had any major surgeries? |
| |
Lifestyle Assessment
Question | Response (1-5)¹ | Comments |
Rate your current level of physical activity. | 4 | I do not tire easily |
How often do you consume alcohol. |
| |
Rate your average daily stress level. |
| |
How would you rate your typical diet? |
| |
¹Responses range from 1 (Very Low/Poor) to 5 (Very High/Excellent)
Consent and Acknowledgment
I hereby confirm that the information provided above is accurate to the best of my knowledge and consent to [Your Company Name] using this information to assist in developing my wellness program.
Employee Signature: ______________________________________
Date: [MM-DD-YYYY]
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