Questionnaire

Please fill your details in below: Mr/Mrs/Ms/Miss: Name: Surname: Address: Telephone Daytime: Telephone Evening: Email: Date of Birth: If you know of a friend and/or colleague that you feel would be interested in the Wellness Experiences, please complete their details here: Mr/Mrs/Ms/Miss: Name: Surname: Address: Telephone Daytime: Telephone Evening: Email: Date of Birth: Age Group: 16 - 25 26 - 40 41 - 60 Social Life: How many really good friends do you have? How many of your friends you could call at 2am in the morning? How would you describe your social life? (select from the menu) Always out with friends - healthy pursuits Always out with friends - unhealthy pursuits Active Quiet Happy Quiet - dull-boring Lonely Non-existent How would you describe your usual disposition? Very happy Happy Satisfied Unhappy Angry Anxious Bored What do you feel is your average stress level? Low Average High Very High Do you consider that you are a highly effective person? If yes, why: If no, why: Do you consider yourself a creative person? If yes, why and how: If no, why: Work-Life Balance Work 10/90 Life Work 30/70 Life Work 50/50 Life Work 70/30 Life Work 90/10 Life Exercise: Do you feel your body moves well? Yes No How often do you exercise? A couple of times a month Once or twice a week Three to four times a week More than fours times a week What type of exercise do you do? Aerobic/cardiovascular Weight training Other Diet: How do you see your body (in terms of size- just right, too thin, overweight)? Does your weight and shape match your body ideal? Yes No Do you consider your diet to be a healthy diet? If yes, why? If no, why? Do you feel refreshed after a nights sleep - do you get up raring to go? Yes No Do holidays refresh you? Yes No