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Sample Wellness Individual Interest Survey

Large businesses may prefer to do this, or similar, surveys by computer to reduce data entry and analysis time. Businesses with few employees can easily compile the information by hand.

This short survey is designed to get a feel for where employee interests lie, while at the same time giving employees a chance to better understand the concept of a wellness program. All responses will be kept anonymous.

Select one number for each question:

4 = Very likely
3 = Somewhat likely
2 = Not very likely
1 = Not at all likely        

1. I buy heart-healthy snacks when they are available (for example, pretzels, cereals, yogurt, one percent or skim milk, fresh fruit, 100 percent juice, raisins or other dried fruit. NOT candy, chips, pastry, etc.).

          4          3          2          1

2. If I had a five-minute break I would use it for a personal activity like stretching, yoga or a walk if there were a place to do it.

          4          3          2          1

3. 1 would eat fruit if available at our staff meetings. 

          4          3          2          1

4. I would participate in group activities encouraging healthy eating or physical activity if they were offered to staff.

          4          3          2          1

5. I am satisfied with my current state of health.

          4          3          2          1

6. I make time for 30 minutes of physical activity most days of the week.

          4          3          2          1

7. I don’t think about health when deciding what to eat.

          4          3          2          1

8. It’s hard for me to get as much exercise as I should.

          4          3          2          1

9. I try to look for healthier foods, but usually eat whatever is available.

          4          3          2          1

10. I don’t know what is meant by “worksite wellness.”

          4          3          2          1

11. Healthier people are more productive at work.

          4          3          2          1

12. Paying attention to healthy eating and exercising is a lot of trouble.

          4          3          2          1

13. I know what it takes to lead a healthy lifestyle.

          4          3          2          1

14. Whether or not to live a healthy lifestyle is completely up to the individual.

          4          3          2          1

Additional comments are welcome. Please write them on a separate sheet of paper. If you want to know more about this program and how you can help, please contact your supervisor.