Key Instincts Personal Assessment

I have a fun/fulfilling work environment* This field is required.

I enjoy coming to work and doing my job* This field is required.

I participate in activities outside of work with my colleagues* This field is required.

I feel supported by my company to have a great Work/Life/Wellness Balance* This field is required.

I take small breaks during my work day to properly REFUEL my body and mind* This field is required.

I have had ___ sick days in the last 3 months* This field is required.

I utilize the Health/Wellness benefits provided by our company* This field is required.

I maximize or would maximize Massage, Acupuncture, Chiropractic services* This field is required.

I maximize or would maximize Counselling services* This field is required.

I maximize or would maximize Dental services* This field is required.

My Energy level throughout the day meets all my daily needs* This field is required.

I take time to “Unplug” from work and technology in the evening and on weekends* This field is required.

I feel I have a well-balanced Work/Life/Health ratio* This field is required.

I take time away from the office during lunch time to recharge and refuel* This field is required.

I learn from my mistakes and develop strategies for personal growth * This field is required.(including asking for help from family, friends and/or colleagues)

I am able to lift basic items in my day-to-day life * This field is required.(groceries, children, household items, etc.)

I am able to move my body with minimal pain or limitation* This field is required.

I enjoy being physically active* This field is required.

I have a routine weekly exercise schedule* This field is required.(minimum 2+ hours)

My weekly exercise consists of Cardiovascular exercise* This field is required.(minimum 3 moderate hours or 1.5 vigorous hours per week)

My weekly exercise consists of strength training* This field is required.(minimum 2 times per week)

My weekly exercise consists of Flexibility/Stretching exercises* This field is required.(minimum 3 times per week)

The hours of uninterrupted sleep per night I receive on an average is* This field is required.

I am happy with my current body weight AND my body composition* This field is required.

Health and Wellness is not just about physical activity and nutrition, depression and stress have been proven to be a major cost in productivity and sick time at work.

I enjoy a daily diet with a variety of healthy foods* This field is required.

I eat 3+ servings of vegetables per day* This field is required.

I consume 1-2 servings of fruit everyday* This field is required.

I understand the importance of fiber and consume fiber daily* This field is required.

I avoid eating highly processed foods and drinks* This field is required.(For example: cereals, crackers, white pastries, food and drinks with added sugars, etc.)

I drink a minimum of 2 litres (8 cups) of water per day* This field is required.

I avoid drinking 3 or more caffeinated beverages per day* This field is required.

I avoid drinking sugary or diet drinks* This field is required.

The number of days in a week I drink alcohol and/or use recreational drugs* This field is required.

Overall, I feel that I am on the right path and I am a positive healthy-eating & drinking role model for those around me* This field is required.

I do my best to be present throughout my day in my conversations, my thoughts, my decisions and my reactions* This field is required.

I do my best to use the trials and tribulations of my life (past/present) to learn, understand and grow as a person* This field is required.

I make it a habit to meditate, pray, consciously breathe, consciously move, make time to collect my thoughts and/or do yoga each week* This field is required.

I am aware that I impact the energy of a room, situation, conversation, relationship and interaction* This field is required.

In last 30 days, I have felt tense, anxious, and/or depressed __ days* This field is required.

I have the skills, great habits and determination so I do not self sabotage and/or lose steam in my health goals* This field is required.

What wellness related activities, exercises & programs would you like to see implemented in your organization? Be as specific as possible! We welcome your input!

How would you like to receive benefits in your organization?Check all that apply

A benefit provider

Health spending account

Doesn't matter to me

I don't need benefits

Email (Optional)If you would like one of our team to reach out to you with our Key Instincts 'Key' Recommendations, please enter your email below.

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Email (Optional)If you would like one of our team to reach out to you with our Key Instincts 'Key' Recommendations, please enter your email below.

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Email (Optional)If you would like one of our team to reach out to you with our Key Instincts 'Key' Recommendations, please enter your email below.

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Name

First Name

Last Name

Email (Optional)If you would like one of our team to reach out to you with our Key Instincts 'Key' Recommendations, please enter your email below.

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Company Name (Optional)