Wellness Assessment

Pre-qualification

How did you hear about the program?

Are you a CBP Employee?

Yes

What CBP Program do you work for

What CBP Port of Entry, Station, or Office do you work at?

Please provide your HASH Identification number.

Are you related to a CBP employee

Yes

What is your relationship to the CBP employee?

Please provide the name to the CBP employee you are related to?

What CBP Program do they work for

What CBP Port of Entry, Station, or Office do they work at?

I hereby certify that, to the best of my knowledge, the provided information is true and accurate.(Required)

Yes

Are you a military veteran?

Yes

Branch

Personal Information

First Name(Required)

Last Name

Email(Required)

Phone

Address(Required)

City(Required)

State(Required)

Zip(Required)

DOB(Required)

Social Security last 4 digits(Required)

Client Printed Name or that of Legally Authorized Representative

Upload your ID

Accepted file types: jpg, png, pdf, Max. file size: 3 MB.

Printed Name(Required)

Relationship to Client(Required)

Quality of Life Assessment

Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form

Taking everything into consideration, during the past week how satisfied have you been with your………

physical health?(Required)

mood?(Required)

work?(Required)

household activities?(Required)

social relationships?(Required)

family relationships?(Required)

leisure time activities?(Required)

ability to function in daily life?(Required)

sexual drive, interest and/or performance?*(Required)

economic status?(Required)

living/housing situation?*(Required)

ability to get around physically without feeling dizzy or unsteady or falling?*(Required)

your vision in terms of ability to do work or hobbies?*(Required)

overall sense of well being?(Required)

medication?

How would you rate your overall life satisfaction and contentment during the past week?(Required)

What services are you interested in?

Fitness App

Health and Wellness Room (Pandora Star, Alpha Stim, and Mindful Chair)

Clinical Services (Onsite, Virtual, and Art Therapy-Artistic and Creative Expression)

Alternative Therapies (Chiropractic, Massage, Family Bonding/Therapeutic Art Class, Music, and Equine)

DISCLAIMER

THE ASSESSMENT ASSIGNED BY THE CBP ENDEAVORS WORKFORCE WELLNESS PROGRAM WILL BE COMPLETED AGAIN IN 90 DAYS. THE INFORMATION CONTAINED IN THE ASSESSMENT IS FOR THE DETERMINATION OF YOUR HEALTH AND WELLNESS USE ONLY AND WILL REMAIN CONFIDENTIAL

Pain and Stress Evaluation

What is your average physical pain level?(Required)

Highest physical pain level last 7 days?(Required)

What is your stress level today?(Required)

Highest stress level in last 7 days?(Required)

Feel about your overall fitness?(Required)

Rate your current energy level?(Required)

How would you rate your flexibility?(Required)

How would you rate your sleep?(Required)

Do you feel you get enough sleep at night?(Required)

Thank you!

Sorry, you’re not eligible to fill out the QLES form based on your responses.