Holistic Wellness Assessment

Holistic Wellness Assessment
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Organization Name & Years Employed

Physical Wellness: Rate your current physical wellness on a scale of 1 to 5, with 1 being poor and 5 being excellent
- How would you rate your overall physical health?
 - 1 (Poor) - 2 - 3 - 4 - 5 (Excellent)

- Are you getting sufficient sleep each night?
 - Yes - No - Sometimes

- How often do you engage in physical exercise?
 - Rarely or never - Occasionally - Regularly - Very regularly

- How would you rate your eating habits?
 - 1 (Poor) - 2 - 3 - 4 - 5 (Excellent)

- Are you able to maintain a balanced and nutritious diet?
 - Always - Often - Sometimes - Rarely - Never

Additional Comments on Physical Wellness: What are your goals? What have been your barriers? What will success look like to you? 

2. Mental Wellness: Rate your current mental wellness on a scale of 1 to 5, with 1 being poor and 5 being excellent
- How would you rate your overall mental health?
 - 1 (Poor) - 2 - 3 - 4 - 5 (Excellent)

- Are you able to manage stress effectively?
 - Always - Often - Sometimes - Rarely - Never

- Do you feel a sense of balance between work and personal life?
 - Yes, always - Most of the time - Occasionally - Rarely - No

Additional Comments on Mental Wellness: What are your goals? What have been your barriers? What will success look like to you?

3. Spiritual Wellness: Rate your current spiritual wellness on a scale of 1 to 5, with 1 being poor and 5 being excellent
- How would you rate your overall spiritual well-being?
 - 1 (Poor) - 2 - 3 - 4 - 5 (Excellent)

- Do you engage in activities that nurture your spiritual well-being (meditation, prayer, mindfulness)?
 - Regularly - Occasionally - Rarely - Never

-What is your relationship with God like? 
 - 1 (Poor) - 2 - 3 - 4 - 5 (Excellent)

Additional Comments on Spiritual Wellness: What are your goals? What have been your barriers? What will success look like to you?

4. Social Wellness: Rate your current social wellness on a scale of 1 to 5, with 1 being poor and 5 being excellent
- How would you rate your overall social well-being?
 - 1 (Poor) - 2 - 3 - 4 - 5 (Excellent)

- Do you have a supportive social network (family, friends, colleagues)?
 - Strongly agree - Agree - Neutral - Disagree - Strongly disagree

- How often do you engage in social activities outside of work?
 - Very often - Often - Occasionally - Rarely - Never

Additional Comments on Social Wellness: What are your goals? What have been your barriers? What will success look like to you?

5. Relational Wellness: *Rate your current relational wellness on a scale of 1 to 5, with 1 being poor and 5 being excellent.*
- How would you rate your overall relational well-being (relationships with family, friends, colleagues)?
 - 1 (Poor) - 2 - 3 - 4 - 5 (Excellent)

- Are you able to communicate effectively with your team and colleagues?
 - Always - Most of the time - Occasionally - Rarely - Never

- Do you feel a sense of connection and collaboration in your professional relationships?
 - Strongly agree - Agree - Neutral - Disagree - Strongly disagree

- Do you feel a sense of holistic wellness among your organization?
 - Strongly agree - Agree - Neutral - Disagree - Strongly disagree


Additional Comments on Relational Wellness: What are your goals? What have been your barriers? What will success look like to you?

Additional Overall Comments
How would you define wellness? 

What does successful wellness look like to you personally?

Professionally? 

Is there anything specific you would like to share regarding your holistic wellness that is not covered in the assessment survey? 

Please feel free to provide any additional comments or suggestions.

Thank you for completing the Workplace Wellness Group Employer Holistic Wellness Survey! Your well-being is important to us, and your contribution will help us create the best approach to your holistic wellness solution.
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