Executive Wellness Onboarding survey

1

Your Name

Prefix

First Name

Last Name

2

Email Address * This field is required.

example@example.com

3

Your Gender

4

How would you rate your current energy levels throughout the day?

high energy all day

strong in the morning, crash in the afternoon

low energy most of the day

fluctuates significantly

5

What are your top wellness priorities? (Select as many as you need)

Weight Management

Increased Energy

Better Sleep

Stress Reduction

Physical Performance

Longevity/ Healthy Aging

7

How many hours per week can you realistically dedicate to your wellness activities?

Less than 2 hours

2-4 hours

4-6 hours

6+ hours

8

Calculation

9

How many hours of sleep do you typically get?

less than 6 hours

6-7 hours

7-8 hours

8+ hours

10

How would you rate your sleep quality?

Excellent (wake refreshed)

Good (occasional disruptions)

Fair (frequent waking)

Poor (difficulty falling/staying asleep)

11

How many hours do you spend sitting daily?

Less than 4 hours

4-6 hours

6-8 hours

8+ hours

12

Rate your current stress level (1-10 scale): (1 low to 10 highest)

1-3 Low stress

4-6 Moderate stress

7-8 High stress

9-10 Severe stress

13

What are your primary sources of stress? (Select all that apply)

Work demands

Family responsibilities

Health concerns

Financial pressure

Time constraints

Other

14

Calculation

15

How often do you currently exercise?

Never

1-2 times/week

3-4 times/week

5+ times/week

16

What type of exercise do you currently do? (Select all that apply)

Cardiovascular training

Weight training

Flexibility work

Sports activities

None currently

18

Calculation

19

How many meals do you typically eat per day?

1-2 meals

3 meals

4-5 meals

6+ meals

20

How often do you eat out/order takeout?

Rarely

1-3 times/week

4-6 times/week

Daily

21

How many alcoholic beverages do you consume weekly?

None

1-3 drinks/week

4-7 drinks/week

8+ drinks/week

22

Calculation

24

How often do you take breaks during work?

Every hour

Every few hours

Only for lunch

Rarely take breaks

25

What is your typical evening routine?

Screen until bedtime

Reading/ Relaxing

Continue working

Structured wind down routine

26

Calculation

27

When was your last physical examination with your primary/ specialist?

Within 6 months

6-12 months ago

1-2 years ago

over 2 years ago

28

Do you track any of these metrics? (Select all that apply)

Heart rate

Daily steps/ activity

Sleep quality/ duration

Weight

None

29

calculate your BMI

31

Calculation

32

Average weekly work hours:

Under 40

40-45

45-50

50+

33

How often do you travel for work?

Never

1-2 Times/quarter

Monthly

Weekly

35

Calculation

36

CalculationGreen (90-100): Optimal Yellow (80-89): Moderate Orange (70-79): Needs Attention Red (0-69): Critical Focus Required