Protecting Our Health Member Survey

 

Please complete this survey to receive your free copy of What’s Cooking — the first cookbook of healthy recipes for and by 1199SEIU members and retirees. All responses will be kept confidential (except for the one healthy tip that we ask you to share with other 1199SEIU members).

 


YOUR HEALTH

Do you think that you are generally
in good health or not?:
(SELECT ONE)

Yes
No
Not Sure
Do you think you are overweight?:
(SELECT ONE)
Yes
No
Not Sure
 

Do you exercise?:
(SELECT ONE)

Yes
No

How often?:
(SELECT ONE)

Once/week
Two times/week
3-4 times/week
5 times/week
Daily
More than daily

What kind of exercise?:
 
Do you have a chronic condition?:
(Example: asthma, diabetes, hypertension, cancer, etc.)
Yes
No

If yes, what?:
Your Goals
Do you feel that you need to improve your health?:
(SELECT ONE)
Yes
No
Not Sure

If yes, what would you want to improve?:
(SELECT ALL THAT APPLY TO YOU)
 Eat a healthier diet
 Be more physically active
 Control my blood pressure
 Monitor my blood sugar and keep it under control
 Deal better with stress
 Stop smoking
 Get regular check-ups and cancer screenings
 Lose weight
Other:

 

What would be the hardest thing to overcome to reach your goal?:

 

Personal Information:

 bold = required

You must complete the following in order to receive your cookbook by mail.
First Name:
Last Name:
Home Address:
City:
State:
Zip:
Email:
Phone:
Are you an 1199SEIU Member or Retiree?  Member   Retiree
Are you an 1199SEIU Staff Member?  Yes  No

If Yes, do you work for:

Union
BPF
TEF
CCF
Where you work/worked:
( 1199SEIU Institution)
Last four digits of your Social Security Number: xxx-xx-
How did you hear about
What’s Cooking?:
 I would like to receive more information about the Benefit Fund's Protecting Our Health campaign
Is the above your Mailing Address as well?:
Yes
No
Your Healthy Tip (Optional)

Share a tip for healthy living with other 1199SEIU members. (check the www.1199SEIUbenefits.org periodically!  Your tip may go on the website!)
 
 

 

 

Member Benefits Finder

Enter your employer's name to find your specific benefits information. If you are a retiree, click here.

Please search for your employer using the field below:

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