UDC Workplace Wellness Survey

Sex

Male

Female

Age

0

Section 2 Current Level of Wellness

Are you overweight (defined as having body mass index (BMI) of 25-30) or obese (BMI over 30)? (BMI formula: your weight in pounds ÷ your height in inches x 703)

Yes

No

Are any of your dependants overweight or obese?

Yes

No

Do you smoke?

Yes

No

Do any of your dependents smoke?

Yes

No

Are you or any of your dependents currently being treated for any of the following? (please check all that apply)

High Blood Pressure

High Cholesterol

Diabetes

Depression or other mental health issues

Stress Management

Other (please list)

Has your medical professional recommended that you or any of your dependents? (please check all that apply)

Lose weight

Stop smoking

Get more exercise

Lower your cholesterol

Lower your blood pressure

Seek counseling for mental or emotional health

Other (please list)

Section 3: Wellness Interests