Employee Wellness Assessment Form
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
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Date: |
[Month Day, Year] |
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Employee Name: |
[Your Name] |
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Department: |
[Your Work Department] |
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Position: |
[Role/Position] |
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Date of Birth: |
[Month Day, Year] |
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Gender: |
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Contact Number: |
[Phone Number] |
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Email Details: |
[Email Address] |
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Health Information
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Question |
Response (Yes/No) |
Details/Comments |
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Do you have any known allergies? |
No |
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Are you currently taking any medications? |
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Do you have any chronic health conditions? |
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Have you had any major surgeries? |
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Lifestyle Assessment
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Question |
Response (1-5)¹ |
Comments |
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Rate your current level of physical activity. |
4 |
I do not tire easily |
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How often do you consume alcohol. |
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Rate your average daily stress level. |
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How would you rate your typical diet? |
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¹Responses range from 1 (Very Low/Poor) to 5 (Very High/Excellent)
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Wellness Goals |
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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]
