Step 1 of 3 33% What is your name? (First and Last) *(Required)What is your current age?(Required)What is your current age?What is your current age?18-2425-3435-4445-5455-6465+What is your gender identity?(Required)What is your gender identity?What is your gender identity?FemaleMaleNon-binaryPrefer not to sayOtherPlease list how you identify if applicable.(Required)Please list how you identify if applicable.Please list how you identify if applicableCBP EmployeeCBP Spouse or Household MemberSurviving Spouse of CBP EmployeeCBP RetireeHow did you hear about the CBP Wellness Program?(Required)How did you hear about the CBP Wellnes Program?How did you hear about the CBP Wellness Program?Social MediaEmailMailFriend/Family/ReferralOutreach EventTelevisionOtherHow satisfied are you with the following areas currently regarding your overall health?(Required)Very UnsatisfiedUnsatisfiedNeutralSatisfiedVery SatisfiedPhysical HealthMood/AttitudeWorklife/RetirementSocial RelationshipsFamily RelationshipsHobbies/Leisure timeEconomic StatusAbility to function in daily lifeHow satisfied are you currently with the following areas regarding your overall health?(Required)Very UnsatisfiedUnsatisfiedNeutralSatisfiedVery SatisfiedLiving/HousingAbility to get around physically without feeling dizzy or unsteady or fallingOverall sense of well beingOverall life satisfaction and contentment during the past weekAbility to ExcerciseDiet NutritionEnergy level through out the dayMobility/Movement What aspect(s) of your wellness would you like to improve?(Required)Mind/Body- Balancing your physical and mental wellbeingKnowledge- Gaining information and resources to strengthen, support, and enhance your health.Connectedness- Promoting community engagement to decrease isolation.Spirtuality- Embracing the spiritual diversity to feed the deepest needs of oneself.Environmental- Including nature and beauty as essential needs for wellbeing.Economic- Incorporating value-based financial wellness, education, and support.On average, what is your physical pain level on a scale of 1-10?(Required)No Pain23456789UnbearableWhat was your highest physical pain level in the last 7 days?(Required)No Pain23456789UnbearableWhat is your stress level today on a scale of 1-10?(Required)No Stress23456789UnbearableWhat was your highest stress level in the last 7 days?(Required)No Stress23456789UnbearableDo you use Tobacco products?(Required)Do you use Tobacco products?Do you use Tobacco products?YesNoWhat form of delivery do you use Cigarettes Vape Dip Pipe Smokeless Cigars IDo you wish to have support on reducing or stopping your usage?(Required)If you use tobacco, do you wish to have support on reducing or stopping your usage?Do you wish to have support on reducing or stopping your usage?YesNo If you were to consume an alcoholic beverage, on average, how many alcoholic beverages would you say you consume in a week? (A standard drink is equivalent to 12oz of beer, 5oz of wine, and 1.5oz of liquor)(Required)If you were to consume an alcoholic beverage, on average, how many alcoholic beverages would you say you consume in a week? (A standard drink is equivalent to 12oz of beer, 5oz of wine, and 1.5oz of liquor)If you were to consume an alcoholic beverage, on average, how many alcoholic beverages would you say you consume in a week? (A standard drink is equivalent to 12oz of beer, 5oz of wine, and 1.5oz of liquor)0 drinks1-2 drinks3-6 drinks7-9 drinks9-12 drinks12+ drinksWould you like assistance/support with reducing or stopping your alcohol use?Would you like assistance/support with reducing or stopping your alcohol use?Would you like assistance/support with reducing or stopping your alcohol use?YesNoDo you use any illicit drugs?Would you like assistance/support with reducing or stopping your alcohol use?Do you use any illicit drugs?YesNoIf yes, would you like assistance/support in reducing or stopping your drug use?If yes, would you like assistance/support in reducing or stopping your drug use?If yes, would you like assistance/support in reducing or stopping your drug use?YesNoDo you have anything you wish to add?
