We are planning Employee Health Promotion Programs to help you feel better and maintain your health. In order to plan programs that best meet your needs and interests we would like your suggestions! Please take a few minutes to answer some questions about your interests. Your answers will be combined with those of others’ and reviewed to help plan programs for you. Do not sign your name.

Please complete the survey today and return it to__________. Thank you for your valuable input! Your help is valuable for creating thriving programs. Return the completed form by _____________.

Rate your interest on a scale of 1 – 3 with one (1) being of little or no interest; two (2) being of some interest and three (3) indicating that you are very interested. Indicate your response by circling or ‘Xing’ the number.

I am interested in:

Participating in wellness programs before work 1 2 3
Participating in wellness programs after work 1 2 3
Participating in wellness programs during my lunch break 1 2 3
Adopting healthy eating options to lose weight 1 2 3
Sports nutrition 1 2 3
Healthier cooking 1 2 3
Helping my children eat healthier 1 2 3
Quick, healthy meals for hectic lifestyles 1 2 3
Healthy snack options 1 2 3
Learning how to quit smoking 1 2 3
Attending classes to help me quit smoking cigarettes 1 2 3
Stress Mangement skills 1 2 3
Balancing work, family, and personal life 1 2 3
Time management skills 1 2 3
Participating in a beginning fitness program 1 2 3
Creating time to exercise for busy people 1 2 3
Getting health information that I can read or watch at home 1 2 3
Learning about cancer prevention 1 2 3
Heart health options 1 2 3
CPR and First Aid 1 2 3
Team sports activities at work 1 2 3
Learning how to stretch 1 2 3
Learning how to boost intake of fruits and vegetables 1 2 3
Parenting Topics (age of children: ) 1 2 3
Onsite exercise classes: walking Yoga aerobic other: 1 2 3
Health evaluation such as Blood Pressure (BP), blood lipids, blood glucose 1 2 3