Free Employee Wellness Assessment Form Template
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] |
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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] |
Health Information
Question |
Response (Yes/No) |
Details/Comments |
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
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. |
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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)
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]