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Short Wellness Pre-Program Questionnaire

Please Note: This is a short version of our comprehensive Wellness Program Questionnaire that can be purchased in paper or online access format in our Wellness Program Support Centre. The full version takes a maximum of 45 minutes to complete and measures fifteen (15) different wellness factors.

There are five stages people go through when making lifestyle changes. To decide if you are realistically going to participate in a Wellness program, please answer the following questionnaire.

Rate your agreement on a scale of 1-5, where 1 means "I do not agree at all" and 5 is "I agree fully".

To the right is a list of attitudes that go with each of the stages of change.

Please be honest - we are not tracking your individual answers, just the totals and deciding if implementing a Wellness Program will be successful in your office. Also, all questions must be filled in, as a blank answer results in a negative (0) response.

If you were given a company identifier, please enter it here (else leave it blank):

  1. Choosing to live a healthy lifestyle (or not) is completely up to the individual. Disagree Agree
  2. Healthier people are more productive at work and at play. Disagree Agree
  3. It takes a lot trouble to pay attention to eating healthy and getting exercise, and I don't have the time right now. Disagree Agree
  4. I am satisfied with my current state of health. Disagree Agree
  5. I make time for 20 or more minutes of physical activity most days of the week. Disagree Agree
  6. I am satisfied with my current state of mind. Disagree Agree
  7. I buy healthy snacks when they are available (for example, pretzels, cereals, yogurt, 1% or skim milk, fresh fruit, 100% juice, raisins or other dried fruit, NOT candy, chips, pastry, etc.) Disagree Agree
  8. I would eat fruit if available at our staff meetings. Disagree Agree
  9. I would participate in group activities encouraging healthy eating or physical activity if they were offered to staff. Disagree Agree
  10. I would use resource guides for healthy eating or physical activity (for example, how-to books, videos, and recipes) if they were available. Disagree Agree

You can find workplace wellness statistics and quotes among other great wellness program tools at our Wellergize.ca site.


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Stages of Making Changes
  1. Precontemplation: Exercise? Yeah, I get exercise - I walk out to my car each morning.
  2. Contemplation: Yeah, I could stand to lose a couple of pounds - maybe I'll go on a diet. Next week.
  3. Preparation: OK, I bought the exercise tape and compiled this list of tips. I should do this. Yes, starting tomorrow.
  4. Action: Woo Hoo! I feel pretty good here on day 10 of my reduced sugar and long walks regimen.
  5. Maintenance: I walk for an hour each day, or I go to the gym three times a week, and I have been for at least six months.

Need more workplace wellness information & support?

NaturalHealthcare Wellergize: Workplace Wellness Programs with the Natural Health slant has created a dedicated site with a wide range of tools and services for workplace wellness: Wellergize.ca

On Wellergize.ca, you can find:
Making a Business Case for Wellness? • Our popular "Business Case for Wellness" cartoons, with Canadian stats
posters and program support materials
• our 15 different wellness challenges
workplace wellness blog
• seminar & lunch and learn series (topics and speakers)
useful stats and quotes
• glossary
• and much more...

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