This questionnaire will be used to assess a variety of aspects about your health, wellbeing, and performance. We will ask you questions about your sleep, physical activity, nutrition, and mental health so that we can provide you with some feedback on your strengths and any areas that can benefit from growth. Please answer the questions to the best of your ability.

Confidentiality statement

We will respect your privacy. Only members of the Wells Group Team will have access to the data. No information that you provide will be given to anyone outside The Wells Group or be published without your permission, unless required by law. For example, if you have an illness that could spread to others, if you talk about suicide, or if the court orders us to give them the questionnaire data.

The data obtained from this questionnaire will be stored in a secure, encrypted location. Published program results will not reveal your identity but will report group mean and other group statistical data only.

Name *
Name
Today's Date
Today's Date
Do you have any current or past injuries (low back pain, knee pain, etc.)? *
Do you have any current or past major health concerns (heart disease, cancer, diabetes, etc.)? *
SLEEP
Add up all the time spent awake if there are multiple awakenings.
1 = very bad 10 = very good
EXERCISE
What type of light activities do you do during the weekdays? *
Check all that apply.
What type of moderate activities do you do during the weekdays? *
Check all that apply.
What type of high-intensity activities do you do during the weekdays? *
Check all that apply.
What type of light activities do you do during the weekend? *
Check all that apply.
What type of moderate activities do you do during the weekend? *
Check all that apply.
What type of high-intensity activities do you do during the weekend? *
Check all that apply.
1 = very bad 10 = very good
NUTRITION
One serving of vegetables is approximately one fist.
One serving of starch is approximately a cupped hand.
One serving of protein is approximately one palm.
One serving of protein is approximately one palm.
One serving of fat is approximately one thumb.
One serving of fat is approximately one thumb.
One banana, one medium-sized apple, two plums, one cup of berries are all considered one serving of fruit.
Including chocolate, cookies, candy, chips, pop, etc.
Including coffee, tea, soft or energy drinks (e.g. Coke, Redbull), and supplements.
What is your typical caffeine source? *
Check all that apply.
One alcoholic beverage is approximately 12 oz of beer, 5 oz of wine, or 1.5 oz of distilled liquor.
What kind of foods do you normally crave? *
Check all that apply.
1 = very bad 10 = very good
FOCUS
Tell us about how well you focus during a typical workday. *
Tell us about how well you focus during a typical workday.
I use my time efficiently.
I am able to focus solely on one task before moving on to the next.
I am able to concentrate on tasks throughout the day.
I am able to block out distractions to focus on a task.
I arrange my schedule so that I can work on tasks that require the most concentration during the time of day when I am most alert.
I try to create an optimal environment when I really need to concentrate (e.g. close the door, put up a do-not-disturb sign, turn off notifications, etc.).
I take regular healthy breaks throughout the day (walk, listen to music, meditate, etc.).
When I get into the groove of doing something, almost nothing can get me out of it.
STRESS
Tell us about your stress levels during a typical workday. *
Tell us about your stress levels during a typical workday.
I often feel that my life consists of a relentless set of demands that I'm expected to meet and tasks I have to complete.
I frequently find myself feeling irritable, impatient, or anxious.
I am often exhausted.
I have frequent arguments with people.
Most of the time I feel I have very little control over my life.
My mind is running so fast I find it hard to concentrate.
I find it hard to leave work at work.
I often work on evenings and weekends and/or I rarely take a tech-free holiday.
PERFORMANCE
Tell us about your ability to perform at a high level during a typical workday. *
Tell us about your ability to perform at a high level during a typical workday.
I am confident that I can complete most tasks at a high level.
I am able to meet or exceed other people's performance expectations of me.
Before beginning a task, I set an approximate time limit as to how long I will work on it.
I prioritize my work to get the most important task done first.
I take time for reflection, strategizing, and thinking creatively.
I am motivated to exercise during the day.
I practice mindfulness/meditation.
I purposely choose foods that will help me perform at my best.
1 = no stress at all 10 = very stressed
What strategies (if any) do you use to cope with stress? *
Check all that apply.
1 = very bad 10 = very good
1 = very bad 10 = very good
What aspect of your health, wellbeing, or performance are you most interested in focusing on or improving? *
Check all that apply.