SHC Wellness Survey
Let the SHC team know about your wellness needs, questions, and concerns. By filling out this confidential survey, you will receive an email with personalized feedback, tips, and information about caring for yourself. Chose which information you would like to share with us!
Tell us about yourself! What is your name?
Please provide an email where we can send your personalized wellness feedback:
In general, I would say my health is...
Do you suffer from any chronic conditions or disease? Please explain
How often do you experience stress and anxiety?
Frequently, at least once a day
Can you usually pin point where your stress is coming from?
Please indicate which activities you participate in to relieve stress
Deep breathing, mindfulness, or meditation
Avoiding excess sugar and fats
Talking about problems with therapist or friends
Anti anxiety medications
How many hours of sleep do you usually get a night?
10 or more
Are you looking to manage any chronic or acute pain?
No, but I know someone who can benefit from this information
How often do you drink?
I do not
1-2 drinks per week
3-6 drinks per week
two or more drinks a day
How often do you smoke?
I do not smoke
1-4 cigarettes a day
5 or more cigarettes a day
Do you currently take any medications? Please describe
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service