Age: Gender: Male Female School: SAS SN SNR GS Status: Commuter Resident

What are your primary health concerns?

Please select the following Leading Health Indicators that you would like to learn more about to improve your health: Physical SafetyMental Health
Overweight & ObesityInjury & Violence
Tobacco UseEnvironmental Quality
Substance AbuseImmunization
Responsible Sexual BehaviorAccess to Health Care

What additional health issues/topics are of interest to you?

Where do you get your health care information when you have a question? A friendA DoctorHealth Services Office
Online WebsiteMagazineOther

Where would you like programs to be presented on campus? Informal groups in residence hallGroup session in Health Services Office
In-classroom presentationsWorkshops in Student Campus Center or the Wellness Center

Are you interested in holistic health? Yes No
If yes, please select what you would most like to learn about:
MeditationReikiTherapeutic Touch
YogaReflexologyOther

When would you most likely attend programs being presented?

Monday

Tuesday

Wednesday

Thursday

Friday

12pm - 2pm12pm - 2pm12pm - 2pm12pm - 2pm12pm - 2pm
3pm - 4pm3pm - 4pm3pm - 4pm3pm - 4pm
6pm - 9pm6pm - 9pm6pm - 9pm6pm - 9pm