Name:

Department:

Date of Birth:

Employment Status:

• Full-time

• Part-time

• Contractor

Have you experienced any recent illnesses?

• Yes (pls. specify):

• No

Do you have any chronic health conditions?

• Yes (pls. specify):

• No

Are you currently taking any medications?

• Yes (pls. specify):

• No

Do you feel safe in your work environment?

• Yes

• No (pls. specify):

Are you provided with necessary safety equipment?

• Yes

• No (pls. specify):

Are there any areas of concern regarding workplace safety?

• Yes (pls. specify):

• No

Do you feel stressed at work?

How would you rate your stress level?

• Low

• Moderate

• High

Are you satisfied with your work-life balance?

• Yes

• No

How would you rate your overall well-being?

• Poor

• Fair

• Good

• Very Good

• Excellent

Any additional comments or concerns?