Wings Personal Effectiveness Seminar Wellness Questionnaire

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  • Thank you for participating in our seminar. Please help us improve the effectiveness of Wings Seminars by answering this survey. We use the results of your survey to improve the impact of Wings on your health, wellness, and relationship with your employer. We will ask you to fill this survey out before, immediately after, and six months after you attend a seminar; we ask for your name and birthdate so we can track changes over time. This information is kept strictly confidential. We may share aggregated summaries with outside agencies, but we will not disclose your personal information or individual responses to any outside parties.
  • Health and Wellness:

    (From the World Health Organization’s Health-Related Quality of Life Survey and La Clinica Patient Activation Survey)
  • 1. Would you say that in general your health is: (pick one)
    ExcellentVery GoodFairPoorDon't know/Not sure
  • 2. Now, thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 was your physical health not good?
  • 3. Now, thinking about your mental health, which includes, stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
  • 4. During the past 30 days, for how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
  • 5. I take an active role in my own health care and overall well-being.
    Strongly agreeAgreeDisagreeStrongly disagree
  • 6. Taking an active role in my own health care is the most important factor in determining my health and well-being.
    Strongly agreeAgreeDisagreeStrongly disagree
  • 7. I am confident that I can maintain lifestyle changes like diet and exercise even during times of stress.
    Strongly agreeAgreeDisagreeStrongly disagree
  • Employer Relationship:

    (La Clinica Employer Relationship survey, inspired by Quantum Workplace 2013 Employee Engagement Survey and Baldridge ‘Are we Making Progress’ Survey)
  • Please state how much you agree or disagree with the following statements. Please skip this section if you do not work for an organization (unemployed, retired, self-employed, student, or any other reason).
  • 8. I help remove barriers that get in the way of progress at work.
    Strongly agreeAgreeDisagreeStrongly disagree
  • 9. I am committed to my organization’s success.
    Strongly agreeAgreeDisagreeStrongly disagree
  • 10. My organization is a good place to work.
    Strongly agreeAgreeDisagreeStrongly disagree
  • 11. I share my ideas about how we can improve our work.
    Strongly agreeAgreeDisagreeStrongly disagree
  • 12. I know how I fit into my organization’s future plans.
    Strongly agreeAgreeDisagreeStrongly disagree
  • 13. I know how to improve my relationships at work.
    Strongly agreeAgreeDisagreeStrongly disagree
  • 14. I see growth and career development opportunities for myself in my organization.
    Strongly agreeAgreeDisagreeStrongly disagree
  • This field is for validation purposes and should be left unchanged.