09 05

Survey questions for health and wellness

You have been selected to participate in a focus group regarding your UPI benefit programs.

Please complete this confidential survey by close of business Friday, September 9th to be entered into a drawing for a Subway gift certificate!

Your feedback is very important to UPI as we plan future programs and communications. We ask that the content of this survey remain confidential until programs are communicated.

Thank you in advance for your participation.

survey questions for health and wellness

Sample Survey Healthcare Opinion Survey Template

survey questions for health and wellness Health, Nutrition, and Lifestyle Surveys | SurveyMonkey

This is the questionnaire that deals with health care and your involvement in health care. Please take a few minutes to express your opinions about the availability and quality of health care in your community. Your answers are important to the success of this study.

Thank you for your assistance.

Please tell us the city, state (or territory), and country you live

Is there a difference in performance between the available hospitals in this area?
Do you have a preferred hospital?
Is there a difference in the cost of the hospitals in this area?
Do you receive pressure from other family members to get health care problems taken care of promptly?
Do you feel comfortable judging the differences between hospitals in this area?
Do you receive care from the same hospital?
Can you be helpful to friends who are having difficulty making section of a hospital?

How many years have you lived in this community?

How satisfied are you with the skill and competency of the staff?
Does the hospital you regularly visit have equipment for modern diagnosis and treatment?
Does the hospital have modern operating room facilities?
How satisfied are you with the following:
Overall cleanliness of the hospital
Efficiency of nursing care
Friendliness and courtesy of staff
Convenience of location for you
What kind of medical insurance coverage do you have?

How many times have you and any member of your family been to your doctor in the last year?

How many times have you visited a friend or loved one in the hospital in the last year?

How many times have you and other members of your family been a patient in a hospital in the last 3 years?

If quality of service is equal, which source of care would you prefer?
If you or a member of your family have received medical care at another hospital while living in the [HOSPITAL] area, why did you choose the other hospital?
When making health care decisions for your family, who is the primary decision maker?
From your experience in the past, when you or a member of your family needs hospital care, who decides on the hospital?

What have you heard about the care patients receive at [Hospital]?

The last section of the questionnaire contains a series of questions about your demographic characteristics such as age and income. We are asking these questions in order to determine if various groups have different opinions and attitudes about hospital care. Please answer these personal questions. No one will ever associate these responses with your name.
Age(s) of children living in your household: (Check all that apply)

Total household income (from all sources) before taxes for the year [Year]?

$25,000 or less

$25,000 - $49,999

$50,000 - $74,999

$75,000 - $99,999

$100,000 - $149,999

$150,000 and over

Highest level of formal education that you have completed.

Spouse's primary occupation?

Thank you for your assistance.

Sample Workplace Health and Well-being Survey

ABC Company is looking into the need for a workplace health and well-being program. 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 inter-office mail.


4. Would you like ABC Company to help with these concerns?

Yes No Not sure

Explain your answer

5. Indicate how you feel about the following statements:

Agree Strongly Agree Not sure/
No opinion Disagree Disagree Strongly
On the whole, I like my job.
I feel that I am well rewarded for the effort I put in at work.
I am happy with the balance between my work time and my leisure time.
At work, my level of authority is about the same as my level of responsibility.

6. Which of the following activities would you prefer to participate in? (Check all that you would be likely to join)

Yes No Maybe
Aerobic exercise
Walking Club
Recreational Team (e.g., baseball)
Other exercise programs (specify)
Healthy Backs
Healthy Eating (general tips, etc.)
Weight Management
Blood Cholesterol Testing
Flu Shots
Blood Pressure Screening
Blood Glucose Screening
Body/Mass Index (BMI) Testing
Stress Management (either home/work)
Alcohol / Drug Abuse Education
Smoking Cessation
Marital Situations
Interpersonal Skills (such as "Dealing with Difficult People", Conflict Resolution, etc.)
Retirement Planning
Lunch & Learn Sessions
Time Management
Home Budgeting / Financial Planning
Health Fair (booths)
Balancing Family and Work
Other: (please list)

7. When would you be able to participate?

8. Where would you prefer to attend a program?

Private Health Club
Local School or Facility/Hall

9. If necessary, would you be willing to share in the cost of a program?

Yes No

10. Do you have any additional comments or concerns you would like the committee to know?


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