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Employee Health Survey Form
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Name
*
First
Last
Employee ID
*
Department
*
Email
*
Phone Number
*
Height (in cms)
*
Weight (in kgs)
*
Do you have any existing Medical Conditions or Chronic Illnesses?
*
Select
Yes
No
Don't know
If yes, please elaborate
Exercise & Food Behaviors
Layout
In the past week, how many days did you workout?
*
Select
Every day
4-6 days
1-3 days
Never
Which of these workouts are you most interested in?
*
Brisk Walking/ Jogging
Cycling
Gym Workouts
HIIT
Running
Swimming
Yoga
Zumba
Others
If you selected others, please elaborate
In the past week, how many days did you play a sport?
*
Select
Every day
4-6 days
1-3 days
Never
Which of these sports are you most interested in?
*
Badminton
Basketball
Cricket
Football
Padel
Table Tennis
Tennis
Volleyball
Others
If you selected others, please elaborate
Layout
In the past week, how many days did you eat home-cooked meals?
*
Select
Every day
4-6 days
1-3 days
Never
In the past week, how many times did you order/eat out?
*
Select
2-4 times
4-6 times
6-8 times
>10 times
On a scale of 1-10, how healthy do you think you eat?
Selected Value:
5
1- very unhealthy, 10- very healthy
Mental Health Behaviors
On a scale of 0 to 10, where 0 is ‘never’ and 10 is ‘all the time’, how would you rate…
Your overall sleep quality over the last 3 weeks?
Selected Value:
5
Your overall stress levels over the last 3 weeks?
Selected Value:
5
Your overall anxiety levels over the last 3 weeks?
Selected Value:
5
Your overall energy levels over the last 3 weeks?
Selected Value:
5
Physical Health Behaviors
How is your health in general? Would you say it is…
*
Select
Very good
Good
Fair
Bad
Very Bad
During the last 12 months, have you felt unwell as a result of work related stress?
*
Select
Yes
No
Don't know
Do you face muscular or joint issues which are a result of prolonged sitting at your desk?
*
Select
All of the time
Most of the time
More than half of the time
Less than half of the time
Some of the time
Never
What are your biggest muscular or joint issues?
*
Neck pain
Shoulder pain
Back Pain
Elbow pain
Wrist pain
Others
If you selected others, please specify
*
Do you encounter challenges due to office working conditions? Select the most applicable option:
*
Select
Yes, I regularly face issues
No, I haven't experienced any challenges
Occasionally, but manageable
Not applicable – I don't encounter any difficulties
Initiatives you think that could improve your physical and mental health within the office environment.
*
Corporate sports tournaments
In-office yoga sessions
In-office zumba classes
Steps challenges
In-office laughter sessions
In-office fitness sessions
Team building activities
In-office meditation sessions
In-office health and wellness workshops
Ergonomic office setups
Fitness rewards app membership (Fitze)
Others
If you selected others, please specify
Submit
