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Questionnaire Form

Welcome to our Health Hub. We are really glad you’ve joined this program.

Wellness Score Form

Step 1 of 29

Our aim for this program, is to improve your overall health and wellbeing, educate you in on how to be healthier at work and at home and to connect you with your teams.

Before we get started, we need to establish some benchmarks of your overall health and wellbeing. This will help you to see how you are progressing and provide important information in helping to achieve your goals.

This questionnaire asks you about eating and hydration, sleep, physical activity, alcohol consumption, smoking habits, and wellbeing, and will take you approximately 10 minutes to complete.

All the information collected will be treated as private and confidential, in accordance with current privacy legislation. Any shared information will be about the company as a whole and with no names attached.

Sex*
Male Female Prefer not to say

In the past 4 weeks, how many minutes of structured exercise did you do per week on average? If you perform maximal effort exercise like sprinting, double your minutes.*
>150 minutes (e.g. 30 minutes of exercise, 5 x per week) 100-150 minutes 30-100 minutes Less than 30 mins I don’t exercise

During your workday, how much time do you spend sitting?*
Most of the time A lot of the time Some of the time A little of the time None of the time

Over the past 4 weeks, how often did you have a lot of energy?*
All of the time Most of the Time Some of the time A little of the time None of the time

During the past 4 weeks, how much did physical pain (e.g. back pain) interfere with your work?*
Not at all Slightly Moderately Quite a bit Extremely

During the past 4 weeks, how much of the time has poor physical health and fitness interfered with your life (socialising, chores, work, daily tasks)?*
All of the time Most of the time Some of the time A little of the time None of the time

How often do you eat breakfast?*
Everyday 5-6 days per week 3-4 days per week 1-2 days per week Less than once per week

How often do you eat takeaway meals?*
Everyday 5-6 days per week 3-4 days per week 1-2 days per week Less than once per week

How may serves of vegetables do you eat per day?*
5 or more serves per day 3-4 serves per day 3-4 serves per day Less than one per day I don't eat vegetables

Over the past 4 weeks, how often have you felt downhearted and blue?*
All of the time Most of the time Some of the time A little of the time None of the time

During the past 4 weeks, to what extent have emotional problems interfered with your life?*
Not at all Slightly Moderately Quite a bit Extremely

Over the past month, how often have you felt very nervous or anxious?*
All of the time Most of the time Some of the time A little of the time None of the time

Over the past month, how often have you felt worn out or exhausted?*
All of the time Most of the time Some of the time A little of the time None of the time

Over the past 4 weeks, how often did you feel self-conscious or have low self-esteem/confidence?*
All of the time Most of the time Some of the time A little of the time None of the time

Thinking about your sleep over the past month, how much has poor sleep affected your concentration, productivity, or focus?*
Not at all A little Somewhat Much Very much

In the past 4 weeks, how has poor sleep affected your mood or energy levels?*
Not at all A little Somewhat Much Very much

Do you feel as though you have effective and healthy strategies to manage stress and emotional challenges?*
Yes No

Do you have a close network of friends and family you could turn to in a time of need?*
Yes No

True or False: I feel as though I have a clear purpose in life.*
True False

True or False: I consider myself a happy and content person.*
True False

By submitting this form and registering for the program you accept the terms and conditions and privacy policy.This question is required.*
I accept I don't accept
See terms & conditions - https://www.energyhealthconcepts.com/terms-and-conditions See privacy policy - https://www.energyhealthconcepts.com/privacy-policy

30 Minutes Notification

Did you move every 30 minutes for 5 minutes this week?*
yes No