6. Putting your organization’s name and logo on a self-care and wellness guide indicates your
Survey & Registration Form For Health and Wellness Workplace Department
Your Company is looking into the need for a workplace health and wellness department. We are interested in learning
more about your opinions and interests. Your answers will be used to help plan the program and to decide which types of programs to
offer. Senior management has agreed to let everyone take a few minutes to complete this survey.
Please do not put your name on the form because we would like to keep this survey confidential.
Please return the forms by putting them in a sealed envelope and placing them in the designated office mailbox.
1. Sex:
Male
Female
2. Age Group:
under 21
21 - 30
31 - 40
41 - 50
51 - 60
over 60
3. Do you have any health concerns about yourself, your family, or something arising from the workplace?
4. Would you like Your Company to help with these concerns, BioAge Assessments & Health Appraisals?
Yes
Explain your answer
No
Not sure