Wellbeing Conversation

Personal Record

Please complete the following questions during or after your conversation. All information is confidential and gathered in association with GDPR regulations.

Question Title

1. Personal details

Name

Department

Location

Email Address

Managers name

Question Title

2. In a typical week do you feel that you:

	Yes	Sometimes	No
Drink too much caffeine?	Drink too much caffeine? Yes	Drink too much caffeine? Sometimes	Drink too much caffeine? No
Eat a healthy balanced diet?	Eat a healthy balanced diet? Yes	Eat a healthy balanced diet? Sometimes	Eat a healthy balanced diet? No
Feel stressed?	Feel stressed? Yes	Feel stressed? Sometimes	Feel stressed? No
Feel overweight?	Feel overweight? Yes	Feel overweight? Sometimes	Feel overweight? No
Want to smoke less?	Want to smoke less? Yes	Want to smoke less? Sometimes	Want to smoke less? No
Get enough exercise?	Get enough exercise? Yes	Get enough exercise? Sometimes	Get enough exercise? No
Awake from sleep feeling refreshed?	Awake from sleep feeling refreshed? Yes	Awake from sleep feeling refreshed? Sometimes	Awake from sleep feeling refreshed? No
Drink too much alcohol?	Drink too much alcohol? Yes	Drink too much alcohol? Sometimes	Drink too much alcohol? No
Drink enough water?	Drink enough water? Yes	Drink enough water? Sometimes	Drink enough water? No
Have enough energy?	Have enough energy? Yes	Have enough energy? Sometimes	Have enough energy? No
Have an illness/injury/ache/pain that affects your quality of life?	Have an illness/injury/ache/pain that affects your quality of life? Yes	Have an illness/injury/ache/pain that affects your quality of life? Sometimes	Have an illness/injury/ache/pain that affects your quality of life? No
Manage your finances well?	Manage your finances well? Yes	Manage your finances well? Sometimes	Manage your finances well? No
Want to improve your work life balance?	Want to improve your work life balance? Yes	Want to improve your work life balance? Sometimes	Want to improve your work life balance? No
Enjoy your work?	Enjoy your work? Yes	Enjoy your work? Sometimes	Enjoy your work? No
Events in your personal life are affecting your health?	Events in your personal life are affecting your health? Yes	Events in your personal life are affecting your health? Sometimes	Events in your personal life are affecting your health? No

Question Title

3. My pledge is to:

Drink less coffee, tea, cola

Eat healthily

Try to reduce my stress

Achieve a healthy weight/waist

Stop smoking

Exercise more

Improve my sleep

Drink less alcohol

Drink more water

Improve my energy levels

Improve my relationships

Manage my medical condition or injury better

Manage my finances better

Improve my work life balance

Improve my overall lifestyle

Manage my personal life issues

Other (please specify)

Question Title

4. What support plan have you chosen?

Join the WELL 1-2-1 programme

Contact the EAP

Visit my GP

Book an OH appointment

None at the moment

Question Title

5. Overall, how would you rate the Wellbeing Consultation?

Excellent

Very good

Good

Fair

Poor

Question Title

6. Conversation date

Date / Time

Date

Time

AM/PM

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100% of survey complete.

Wellbeing ConversationPersonal Record

Question Title

1. Personal details

Question Title

2. In a typical week do you feel that you:

Question Title

3. My pledge is to:

Question Title

4. What support plan have you chosen?

Question Title

5. Overall, how would you rate the Wellbeing Consultation?

Question Title

6. Conversation date

Wellbeing Conversation

Personal Record